Submission by the Catholic Medical Association (UK) to the Health and Social Care Committee in relation to assisted dying


LogoThe Catholic Medical Association (UK) represents Catholic doctors, nurses, pharmacists, hospital chaplains and other healthcare professionals within the UK. It celebrated its centenary in 2011.

The CMA (UK) welcomes this opportunity to respond to the consultation on Assisted Suicide.

Executive summary

Detailed responses are given to the first three questions only in relation to the impact of assisted suicide on palliative care. The effects of assisted suicide and assisted dying (MAID) are referenced with respect to the situation in Canada which will permit assisted suicide and active euthanasia for mental illness from March 2023. This is likely to further change the demographics of suicide by making assisted suicide a solution to those who have considered or attempted suicide.

“Assisted dying” and “assisted suicide” are not equivalent terms. Helping someone to die is not the same as helping someone to kill themselves. Good palliative care can achieve the former with­out ever directly intending to kill someone or to help them kill themselves. The CMA does not accept it is ever right directly to intend to help someone to commit suicide.

An essential issue regarding safeguards is that they cannot be effective for the person who has died. Furthermore, there is less incentive in addressing abuses e.g. undue pressure or coercion, if assisted suicide itself is no longer unlawful.

Q1. Do people in England and Wales have access to good palliative care? How can palliative care be improved, and would such improvements negate some of the arguments for assisted dying/ suicide?

Good palliative care is strongly supported by the public and the medical profession. It significantly improves the quality of clinical care for the dying and those with painful or disabling conditions and is cost effective. However, it is under­resourced, and this has led to a misplaced demand for assisted dying.

Nature and accessibility of palliative care services.

Palliative care comprises a multi-agency partnership between patients and providers including healthcare professionals, voluntary workers, carers, families, and friends working together to meet wide-ranging clinical, financial, social, psycho­logical, and spiritual needs. Palliative care supports those needing care towards the end of life as well as those with other complex progressive, life limiting conditions like motor neurone disease.

Pioneered in this country, the ethos of palliative care for those who are seriously ill and dying is focussed on the individual, and their true and inherent dignity. “You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.” (Cicely Saunders). Effective pain management and insistence that dying people needed dignity, compassion, and respect, as well as rigorous scientific methodology to optimise treatment, are the cornerstones of palliative care.

Most of the cost of palliative care comes from charitable giving, local fund-raising and charity shop retail activity. In contrast to other health care services, only a third of funding for palliative care services is provided by the NHS. [1,2] This results in an estimated 100,000 dying people in the UK annually being denied the palliative care they need. To counter this, the government enacted the Health and Social Care Act 2022 which requires local integrated Care Systems to provide palliative care services, but this has yet to be operationalised.

Future need for palliative care

The UK has an ageing population and by 2050, one in four people will be aged 65 years or over and by 2040, demand for palliative care will increase by 25% to 47%, due to complex multiple long term health conditions including cancer and dementia.[3]

Costs and cost-effectiveness of palliative care

The majority of hospice and community palliative care services are provided by charitable sources. In 2013 Hospice UK estimated that only 32% of the funding came from Government. In 2017-18 hospices in the UK spent £969 million on care. However, 60% of end-of-life spending is still on patients in hospital.

A National Audit Office review in 2008 estimated that costs in the last year of life were 30% lower for palliative care patients than for others. Further reviews suggest that costs of care per setting or model of care reflect higher costs for care in acute hospitals with medium costs for nursing care and hospice care and lower costs for care at home (where main healthcare, social and informal care providers are from the community). Hence, the evidence suggests that the existing breadth of palliative and end of life care interventions in the primary, social and community care settings are potentially cost-saving and cost-effective.

Effect of assisted suicide proposals on those who provide palliative care services in the UK

Dame Cicely Saunders, like most working today in the field of palliative care, was firmly opposed to euthanasia and assisted suicide, holding that 'anything which says to the ill that they are a burden to their family and that they are better off dead is unacceptable'. If patients' physical, psychological and spiritual symptoms are properly managed, there is no need for euthanasia. Opposition to euthanasia and assisted suicide is the stance of those doctors who actually provide most of the care to dying people, represented by the Association for Palliative Medicine, the Royal College of GPs and the British Geriatric Society, all of which maintain a policy of opposition.


Palliative care is widely valued by the public and medical profession and it provides cost effective treatment for patients. The evidence suggests a desire from patients and carers for end-of-life care to be moved away from hospital settings to other settings, either at home or in the community. Theoretically, this could represent significant savings by shifting end of life care away from secondary care in hospital.[4]
Nevertheless, there remain serious staff shortages within the NHS and Social Care sectors and the demands for effective end-of-life services will increase due to population demographics and an increase in the number of patients with significant co-morbidities, including dementia.
A move towards medically assisted suicide would be contrary to the ethos and purpose of palliative care and reverse the work of the palliative care movement over the last 60 years. Any such move is opposed by those working in this sector. The majority of palliative care is supported through charitable funding. This demonstrates the strong underlying public support in this area.

Q2. What can be learnt from the evidence in countries where assisted dying/assisted suicide is legal?

Euthanasia or assisted suicide have been legalised in a number of countries including the Netherlands, Belgium, Columbia, Luxembourg, Switzerland, Spain, Germany, Japan, Albania, USA, Australia and Canada. However, on 11th September 2015 the British Parliament over­whelmingly rejected moves towards assisted dying by 330 to 118 votes.

National and international hospice and palliative care organizations are strongly opposed to medical assistance in dying. [5,6,7,8,9,10,11,12] Palliative care focuses on improving the quality of life of those living with life-threatening and chronic painful conditions. Dying is a normal part of life and palliative care does not seek to deliberately and directly cause the death of patients.[13] In Canada it has been estimated that only around 30% of patients have access to palliative care.[14,15] The following account relates to the changes in assisted suicide provision in Canada as an example of how swiftly radical changes in practice can occur.

Medical assistance in dying (MAID)

In Canada, access to hospice and palliative care is not considered a fundamental healthcare right, whereas medical assistance in dying (MAID) is a right for patients through the Canada Health Act. [16] Canada legalised assisted suicide in June 2016 following the Supreme Court case of Carter v Canada in February 2015 and the issues raised there are illustrative of what can be anticipated in England and Wales if the law was changed here. Under MAID legislation, doctors are permitted to prescribe lethal drugs for self-administration (physician assisted suicide) or to administer the medication (active euthanasia by the physician) On 17 March 2021 the law was changed to remove the requirement for the patient to have a fatal or terminal medical condition. However, after 17 March 2023 MAID will be permitted for mental illness. The current eligibility criteria in Canada are that the person must be 18 years or older, have mental capacity, not be under undue influence or coercion, have an irremediable medical illness (or from March 2023 an irremediable mental illness) and be in an advanced state of irreversible decline that cannot be relieved under conditions which are considered acceptable. The criteria must be independently verified by two clinical practition­ers (doctors or nurses). Under the law no one can be forced to provide or help to provide medical assistance in dying.

The number of medically assisted deaths reported in Canada has risen sharply from 1,018 in 2016 to 10,064 in 2021 giving a total of 31,664 since the enactment of the legislation. MAID deaths rose from 2.5% of all deaths in Canada in 2020 to 3.5% in 2021. In 2021 65.6% of MAID deaths were for cancer, 18.7% for cardiovascular disease, 12.4% for respiratory disease and 12.4% for neurological conditions whilst 10% had multiple comorbidities and 8% organ failure. These percentages have remained similar to those in 2020. However, from 17 March 2023 MAID will be legally permitted for mental health problems so that the underlying conditions will no longer be purely medical.

In 2022, 36.4% of deaths occurred in hospital, 35.1% in private residences, 20.6% in a palliative care facility and 6.8% a residential facility. The number of practitioners (doctors and nurses) involved in MAID increased steadily from 1,143 in 2019 to 1,577 in 2021. Nurses were between 4.8% and 5.6% of practitioners. In January 2023, Dr Ellen Wiebe admitted in a webinar that she was responsible for over 400 MAID deaths and a colleague and obstetrician Dr Stefanie Green, revealed she had helped over 300 to die through the MAID program.[17]

Unassisted suicide rates in Canada

In Canada there are 10-12 suicides per day and 4,500 per year with a suicide rate in men which is three times higher than in women. Overall suicide rates per 100,000 have ranged from 10.1 to 12 in recent years with a rate in women of between 5.0 and 6.3 and in men of around 15.2 to 18.7. The absolute number of medically assisted suicides per annum which is in excess of 10,000 is already considerably greater than that of unassisted suicides, with a roughly equal number of men and women and with an increase in the mean age of death with MAID compared to unassisted suicide. There is no doubt that MAID has altered the demographics of suicide in Canada to involve those with underlying medical conditions who would not otherwise have committed suicide. The situation will change further in Canada after 17 March 2023 when MAID for mental illness will become lawful (although the government has indicated it may delay the timing).

Problems raised by MAID in relation to suicide treatment and prevention.

Physician assisted suicide and medically assisted deaths (or direct homicide of a patient) create enormous problems for those dealing with suicidal patients and in managing suicide prevention. There is a danger that threatened suicide which is a real and immediate problem, is solved by assisted suicide. The Canadian legislation will allow MAID for mental illness from 17th March 2023. This raises enormous problems for those involved with the prevention of suicide and care of those who are at risk of suicide.

There remains a lot of disagreement amongst Canadian experts as to whether it is possible to distinguish between a person who is suicidal and one who is requesting MAID due to mental illness. Confusingly, suicide assessment and interventions are part of MAID assessment practice. It is unclear whether the clinicians involved should discourage or authorise the patient’s death. It is likely that medically assisted suicide could become a “solution” for those troubled by suicidal thoughts. Should those who have been hospitalized for attempted suicide then be assessed and advised, or helped, to commit suicide as a final “solution” to their problem? There is a genuine concern that those with mental health issues, dementia and chronic disability will be encouraged to find a clinically administered death as the solution to their difficulties. This has widespread implications for those engaged in the management of those with a potentially fatal psychiatric emergency which is responsible for over 4,000 deaths per year in Canada.

Q3. What are the professional and ethical considerations involved in allowing physicians to assist someone to end their life?

The Hippocratic tradition

The Hippocratic Oath defined the purpose of medicine as to benefit the sick: “wherever I go and whosoever house I enter, there will I go for the benefit of the sick.” Euthanasia and assisted suicide were expressly prohibited. “I will give no deadly drug to anyone nor will I counsel such.”

The Anthropologist, Margaret Mead regarded the Hippocratic tradition as a “priceless possession which we cannot afford to tarnish; yet...“society always is attempting to make the physician into a killer - to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient ..... [it is] the duty of society to protect the physician from such requests.”[18]

Pope John Paul II summarised the position by saying “laws which legitimize the direct killing of innocent human beings through euthanasia are in complete opposition to the inviolable right to life proper to every individual; they thus deny the equality of everyone before the law.... Disregard for the right to life, precisely because it leads to the killing of the person whom society exists to serve, is what most directly conflicts with the possibility of achieving the common good.” [19]

International recognition of the basic right to life

The Preamble to the Universal Declaration of Human Rights (UDHR) (1948) recognises “that the foundation of freedom, justice, and peace in the World” is the “recognition of the inherent dignity and equal and inalienable right of all members of the human family.”[20]

There is a fundamental and inalienable right to life of all human beings which forms the basis for the enjoyment of all other rights. The fundamental human right to life which underlines the inherent dignity, worth and inalienable rights of all human beings must be protected by law.[21,22,23,24,25,26]

The right to conscientious objection and professional integrity in practice.

Medically assisted death through assisted suicide is strongly opposed by those involved in the care of the dying. The right to freedom of conscience is recognised by the World Medical Association, international law and convention and domestic law.[27]


The right to life must remain central to our understanding of human rights and international law. Medicalised killing in the form of assisted suicide and active euthanasia are logically inconsistent with the fundamental principles and philosophy of the UN Declaration and Covenants and the Hippocratic tradition. The fundamental right to life derives from our human nature as members of the human family and must be recog­nised and protected through the rule of law and professional codes of medical ethics.

There is a real risk that the problem of suicide will become the solution. Prevention of suicide will be replaced with procurement of suicide. The inherent problem with safeguards is that they will not be effective if the victim is dead. The decriminalisation of assisted suicide and medicalised killing means it is difficult to apply penalties when MAID goes “wrong.” Furthermore, who will redress any wrongdoing or failures in the system after the primary victims are deceased?

Assisted suicide should not be made legal.

Dr Philip Howard MA GDL LLM MA MD FRCP
On behalf of the Catholic Medical Association UK 18.01.2023


  1. UK Parliament (2022) ‘Post note: Palliative and end of life care’, Available at:
  2. Cost-effective commissioning of end of life care: understanding the health economics of palliative and end of life care. Public Health England. 2017. Chapter 5. Page 35.
  3. UK Parliament (2022) ‘Post note: Palliative and end of life care’, Available at:
  4. Cost-effective commissioning of end of life care: understanding the health economics of palliative and end of life care. Public Health England. 2017. Chapter 5. Page 35
  5. World Health Organization (WHO). “WHO Definition of Palliative Care.” World Health Organization (WHO)
  6. De Lima L, Woodruff R, et al, International Association for Hospice and Palliative Care “Position Statement Euthanasia and Physician-Assisted Suicide.” JPM Vol 20, 1:1 -7.
  7. Radbruch, Lukas, et al. “Euthanasia and Physician-Assisted Suicide: A White Paper from the European Association for Palliative Care.” Palliative Medicine, vol. 30, no. 2, 2015, pp. 104–116., doi:10.1177/0269216315616524.
  8. Australia and New Zealand Society of Palliative Medicine (ANZSPM) “Position Statement on the Practice of Euthanasia and Physician Assisted Suicide.” 31 Mar. 2017
  9. Canadian Hospice Palliative Care Association “Policy on Hospice Palliative Care and Medical Assistance in Dying (MAiD).” Jun. 2019
  10. Canadian Society of Palliative Care Physicians “Key Messages: Palliative Care and Medical Assistance in Dying (MAID).” May 2019.
  11. Statement on Physician-Assisted Dying. American Academy of Hospice and Palliative Medicine (AAHPM), 24 Jul. 2016,
  12. Canadian Medical Association. “Palliative Care (Policy).” 2016
  13. Shariff M & Gingerich M. “Endgame: Philosophical, Clinical and Legal Distinctions be­tween Palliative Care and Termination of Life.” Vol. 85, Second Series Supreme Court Law Review 225. 2018
  14. Quality End-of-Life Care Coalition of Canada and Canadian Hospice Palliative Care Association. “The Way Forward National Framework; a Roadmap for an Integrated Palliative Approach to Care.” Mar. 2015.
  15. Quality End-of-Life Care Coalition of Canada and Canadian Hospice Palliative Care Association. “The Way Forward National Framework; a Roadmap for an Integrated Palliative Approach to Care.” Mar. 2015.
  16. “Fourth Interim Report on Medical Assistance in Dying in Canada.” Government of Canada, Health Canada, Apr. 2019,
  17. Dr Ellen Webe is a member of the Advisory council for dying with Dignity, Canada and Dr Stefanie Green wrote “This is Assisted Dying. A doctor’s story of empowering patients at the end of life.”
  18. Quoted in “Psychiatry and Ethics” 1972. Maurice Levine. Publisher George Braziller. University of Michigan. pp 324-325. ISBN 0807606421 ISBN 9780807606421
  19. Evangelium vitae. John Paul II. 1995. Para 72.
  20. Preamble to Universal Declaration of Human Rights 1948, G.A. res 217A (II), UN Doc A/810 at 71 (1948).
  21. “Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.” (Preamble to the Universal Declaration on Human Rights).
  22. "Everyone has the right to life, liberty and security of person." (Universal Declaration, Article 3).
  23. "Every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life." (ICCPR, Article 6-1).
  24. “Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.”(Universal Declaration Article 2, ICCPR Article 2 (1) CRC Article 2.1).
  25. “Everyone has the right to recognition everywhere as a person before the law.” Universal Declaration Article 6, ICCPR Article 16.
  26. “All are equal before the law and are entitled with­out any discrimination to equal protection of the law.” (Universal Declaration Article 7, ICCPR Article 26).
  27. Article 9 of the International Covenant on Civil and Political Rights (ICCPR) and Article 9 of the European Convention on Human Rights and our domestic Human Rights Act 1998.