Assisted Topping

There is a curious sleight of hand at work in the Assisted Dying debate, and once you notice it the whole thing starts to look less like ethical concern and more like procedural obstruction dressed up as virtue.

Start with the House of Lords. Discounting the Lords Spiritual, whose objections are explicitly theological and therefore beside the point in a secular legislature, what we are seeing is not calm revision but functional filibustering. Hundreds of amendments, many circling the same points, debated at length in a chamber with no guillotine and no electoral accountability. No one needs to shout for hours to kill a Bill. You just bury it under paper until the clock runs out.

And it matters who is doing this. It is not the Lords as a whole. It is a particular cohort. Older, unelected peers. A heavy concentration of hereditaries and Crossbenchers. Retired professional elites with strong personal objections and no democratic mandate to veto a Commons decision outright. Add a small but noisy group of absolutist disability campaigners for whom no safeguard would ever be sufficient, and you have the nucleus of a delaying strategy. The aim is not to improve the Bill. It is to ensure it never quite gets there.

Many defenders say the Lords are merely delaying. But in the context of a Private Member’s Bill, delay is the mechanism of defeat. There is no automatic rollover. Time is finite. Exhaust it and the Bill dies without anyone having to vote it down. So yes, they are delaying. But in this parliamentary context, that is not a lesser sin than blocking. It is simply the polite, British way of doing it while keeping one’s hands clean.

When you strip out the dogma, there is really only one objection that stands on solid ground. The psychiatrists. Their concern about mental capacity, depression at the end of life, and the difficulty of distinguishing a settled autonomous wish from treatable distress is real. It is technical, not moral. It is about judgement under uncertainty, not ideology. And it deserves to be taken seriously, resourced properly, and designed into the law rather than used as a reason to kill it.

But notice what follows logically from that concern. If psychiatrists believe depression may be driving a wish to die, the answer is not an automatic veto. It is treatment, time, and reassessment. That is how medicine already works. We do not assess consent in the middle of delirium, unmanaged pain, or acute distress and then freeze the outcome forever. We stabilise, we treat what can be treated, and then we ask again. If depression lifts and the wish disappears, that tells you something important. If it persists, consistently and coherently, that also tells you something important. What is not defensible is using the possibility of depression as a one way ratchet that blocks choice even after treatment. That is not caution. It is avoidance dressed up as care.

None of this is theoretical. Other countries have been here already, and they did not answer these concerns with sentiment. They answered them with bureaucracy.

Oregon requires two independent doctors to confirm capacity and voluntariness, with mandatory psychiatric referral if either has doubts. Australia, particularly Victoria, went further and built a deliberately cumbersome, multi stage process with mandatory reporting at every step and a statutory review board that audits every case after the fact. Canada recognised that not all cases carry the same risk profile and split its system into tracks, with stricter safeguards where death is not imminent and lighter ones where it clearly is. None of this relies on blind trust in individual clinicians. It relies on duplication, delay, documentation, and audit. Assisted dying regimes work precisely because they are dull.

The same applies to coercion. Other jurisdictions did not wave it away. They hard wired protections into the process. Only the patient can initiate the request. Requests must be repeated and documented. Clinicians must actively assess voluntariness. The process can be paused or stopped at any stage. Every case leaves a paper trail that can be scrutinised later. That is how you deal with subtle pressure. Not by pretending it does not exist, but by designing systems that are robust to it.

The palliative care argument also collapses once you look beyond our borders. No country has made perfect palliative provision a prerequisite, because that would mean doing nothing forever. Instead, they require that alternatives be discussed, documented, and genuinely considered. The evidence from Australia and Canada shows assisted dying operating alongside palliative care, not replacing it. People do not vanish from services the moment they ask a question. The idea that assisted dying becomes a substitute for care is asserted loudly here, but it is not borne out elsewhere.

Which brings us to the workforce and cost arguments, where the sleight of hand becomes most obvious.

We are told assisted dying will overwhelm doctors and nurses, as if end of life care is currently some light administrative afterthought. It is not. It is labour intensive, emotionally draining, and often crisis driven. If a small number of terminally ill people choose an assisted death, some of that work does not happen. Fewer emergency admissions. Fewer late stage interventions. Fewer prolonged deteriorations that everyone knows the outcome of anyway.

This is not crude or callous. It is simply reality. And yet the moment anyone points it out, the response is performative horror. "So you want to kill people to save money?" No. But pretending that costs only ever run one way is not ethics. It is intellectual dishonesty.

Other countries have been far more grown up about this. Canada has published serious modelling showing that the cost of providing assisted dying is lower than the cost of the end of life care that would otherwise have been provided, producing net savings even after implementation costs. The authors are explicit that this must never be a bedside motive. It is a system level observation, not an individual one. Earlier US work points in the same direction. End of life care is disproportionately expensive in the final weeks and months, and assisted dying, used by a very small proportion of patients, reduces some of that expenditure. Not all of it. Enough to make cost neutrality, or modest savings, entirely plausible.

What is notable is how cautious this literature is. No one promises windfalls. No one claims workforce miracles. The claim is simply that the dire warnings of spiralling costs are not borne out, and that once avoided care is counted, the numbers flatten out. No jurisdiction has reported assisted dying as a budgetary crisis. None has reported system overload. None has reported insurance instability or perverse incentives.

The insurance scare story, in particular, dissolves under light scrutiny. In every country where assisted dying is legal, it is treated for insurance purposes as death from the underlying illness, not suicide. Policies pay out. Families are not penalised. Insurers prefer clarity and legality, not moral theatre. This has been settled elsewhere for years, yet it is occasionally wheeled out here as if it were some terrifying unknown.

The workforce impact abroad is similarly unexciting. Australian experience shows assisted dying to be administratively heavy but numerically small. It behaves like a specialist service, not a tidal wave. The evidence points to manageable operational impact, not collapse.

This is exactly the same trick used against Net Zero. Itemise every upfront cost. Amplify every disruption. Treat savings as speculative, distant, or somehow improper to mention. Lower fuel imports, insulation dividends, avoided health costs from cleaner air, resilience against energy shocks, reduced climate damage all quietly disappear from the ledger.

What is also never mentioned is that cheap, abundant renewable energy is precisely what manufacturing has been crying out for. Energy intensive industries do not thrive on volatility and imported fossil fuels priced in dollars. They thrive on stable, low marginal cost electricity. That is how you raise productivity, attract investment, and make British manufacturing competitive again. But that upside is inconvenient, so it is ignored.

Attack the costs. Never mention the savings. Then declare the policy reckless.

As for the slippery slope, this too dissolves under inspection. Other countries have expanded eligibility because legislatures chose to do so. If Parliament is worried about drift, it can write limits, review clauses, and explicit requirements for future primary legislation. That is what lawmaking is for. Governance is not prophecy.

So what is left once the smoke clears? One serious technical concern about capacity assessment that needs addressing properly, and a long list of objections that other countries have already confronted, engineered around, and monitored in practice. Set against that is an unelected chamber using procedure to avoid owning a decision it does not like.

The uncomfortable truth is that the status quo is not neutral. It is a choice. It just happens to be one that keeps suffering off the statute book and on the ward, where it is easier to ignore.