‘Too difficult’ or just too dangerous? The very real danger of coerced death under ‘assisted dying’ laws

By Dr Anni Donaldson (School of Social Work and Social Policy, University of Strathclyde), Dr Mary Neal (School of Law, University of Strathclyde) and Professor David Albert Jones (Director, Anscombe Bioethics Centre) – posted on 12 June 2025

This post was first published in two parts by Scottish Legal News at the following links: Part 1 and Part 2

Experts in domestic abuse, law, and medical ethics argue that the risk of coercion posed by the Assisted Dying Bill needs to be taken more seriously.

One of the main threats posed by assisted dying laws is the danger that people living in abusive situations will be coerced into ending their lives. The Assisted Dying for Terminally Ill Adults (Scotland) Bill currently before Holyrood is no exception. Supporters of assisted dying play down this danger, saying that they see no evidence of coercion in jurisdictions where assisted dying is already lawful, and that providers of assisted dying in these places are trained to identify coercion should it ever occur. What’s more, the Holyrood Bill (proposed by Liam McArthur MSP), like the Leadbeater Bill in England, makes it a specific offence to coerce or pressure another person into requesting assisted dying.  

In this blog, we argue that none of this should reassure us: the threat of coercion under the proposed law is real and significant and must be taken more seriously.

Abuse and coercion in Scotland: high prevalence and low reporting

Those living with domestic abuse and coercive control are not a homogenous group. While domestic abuse is undoubtedly heavily gendered, factors like older age and disability also make people vulnerable to abuse and coercion, and those affected come from every community in Scotland, including minority ethnic and faith communities. An estimated one in three Scottish women live with domestic abuse and coercive control, and according to a poll by Hourglass there are as many as 225,000 older victims of abuse in Scotland.

We know that women are at serious risk of being killed by their abusive partners, and of dying by suicide as a result of domestic abuse: earlier this year, the number of deaths caused by domestic abuse in England and Wales was described by police as ‘staggering.’ Professor Jane Monckton-Smith OBE, a Professor of Public Protection and expert on interpersonal violence, has voiced grave concerns about the impact of assisted dying laws on victims of abuse, warning that ‘[a]ssisted dying could be coerced suicide, or it could be a staged suicide…both are highly likely in domestic abuse.’  Prof Monckton-Smith has criticised proponents of assisted dying for not taking this problem sufficiently seriously, writing: ‘So many victims already take their own lives pushed into it by relentless abuse. Domestic abuse escalates for terminally ill victims. But I’m not seeing this given attention.’ Scottish domestic abuse experts have warned the Committee scrutinising the McArthur Bill that the bill ‘risks offering a new, potentially lethal weapon to abusive men whose partners have been diagnosed with life-threatening or terminal illnesses.’

When supporters of assisted dying speak about ‘choice’ and ‘autonomy’, they should remember that these things are not the reality for women, older adults, and disabled people trapped in abusive and coercive situations.

Those offering reassurances about the risk of coercion betray a lack of knowledge and understanding of the realities and dynamics of coercive control, domestic and elder abuse. Many who live with violence, coercion and abuse are unable or unwilling to talk about it – living with fear and threat becomes normal and abused people deny, even to themselves, that the abuse is going on. Although over 61,000 incidents were reported to Police Scotland in 2023-2024, this still represents a low rate of reporting compared to the actual scale of the problem. Even after the Domestic Abuse (Scotland) Act 2018 criminalised domestic abuse and coercive control, a Scottish Government survey in 2019-2020 found that, although 21% of women over 16 had experienced domestic abuse, almost a third of those abused told no-one about the abuse they experienced, only 10% disclosed the abuse to a doctor, and only 16% of incidents became known to police somehow. All who experience abuse face considerable physical, emotional and cultural barriers to disclosure – those who disclose abuse or coercion risk all manner of unpleasant consequences, from embarrassment and shame to violent reprisals. Recent research has highlighted a number of particular factors that inhibit Scottish women from minority ethnic communities from disclosing abuse to health services and the police.

All of this means that we have a ‘hidden’ population of victims of abuse and coercion in Scotland: it will obviously include people who are or who will become terminally ill, and the abuse doesn’t stop after diagnosis.

Would abuse and coercion be routinely detected?

The ability of health professionals to detect coercion can be improved by training. In recent years, NHS Scotland has introduced training on domestic abuse and other forms of gender-based violence in a selected number of healthcare settings. These are extensive, resource-intensive, time-intensive national training programmes run by specialists. These programmes could presumably be adapted to train those involved in delivering assisted dying, but this would involve significant cost including the cost of providing clinical cover while GPs and other specialists undertake the training. Has the cost of extensively training professionals to spot coercion been factored into the overall cost of implementing the Assisted Dying Bill? In an under-resourced system, the temptation will be to follow the lead of some jurisdictions where assisted dying is already permitted, where doctors and other providers are ‘trained’ to spot coercion in the assisted dying context simply by undertaking a short online module. In Victoria, Australia, providers of assisted dying complete a mandatory 6-to-8 hour online module covering all aspects of the process, with the content related to spotting coercion estimated to amount to only 5 minutes of this. This would be laughable if it weren’t so dangerous and tragic.

In any case, as already mentioned, despite the existence of thorough ‘abuse detection’ training in the NHS at present, the evidence shows that in Scotland, few incidents of abuse are actually disclosed to health professionals.

Abusers have an obvious incentive to conceal their crimes; but victims too may have reason to try to prevent abuse from coming to light. They may be motivated by a misplaced loyalty to the abuser and a wish to protect them from social and legal sanctions. They may be eager to prevent the breakup of the family unit, perhaps for the sake of children. They may be feeling misplaced shame having internalised years and possibly decades of criticism, and of being told that the abuse is their fault. Or they may even be so used to their situation that they now regard it as ‘normal’ and no longer see it as the abuse that it is. Coercive control and psychological abuse will obviously be extremely difficult to detect – even with the best available training – where the victim and the abuser are experienced in concealing it. In many cases, close family are unaware of abuse; professionals who do not know the patient except in a clinical context have even less chance, absent disclosure.

What about the fact that the Bill will make coercion a criminal offence?

The McArthur Bill, like the Leadbeater Bill in England, would make it a specific offence to coerce or pressure another person into requesting assisted dying. But there would need to be grounds for suspecting coercion before anyone could be investigated or prosecuted for these offences, and we have just explained why suspicion is unlikely to be aroused even in many cases where coercion is actually present.

All of this must cast a different light on claims that ‘fears about coercion of vulnerable people are misguided’ and that there is no evidence of coercion in jurisdictions that permit assisted dying. The review procedures in those states tend to be a paper exercise after the fact based on self-reporting by doctors, and those conducting the reviews tend to be supporters of assisted dying and strongly committed to the practice. The former Attorney General of Victoria, Australia, has characterised the system of review in his State as ‘hear no evil, see no evil, speak no evil’. This is a common pattern in other jurisdictions. In Canada, the Office of the Chief Coroner identified over 400 potentially criminal breaches of the law or regulations on Medical Assistance in Dying, but did not refer any case to law enforcement.

In a rare case that was investigated by police in Oregon, Tami Sawyer was charged with criminally mistreating Thomas Middleton, a man who had come to live in her house, and made her a trustee of his finances, shortly before he ended his life under the Death with Dignity Act. After his death Sawyer sold the house, allegedly for $200,000, and transferred the money between a number of companies she owned. This came to light as part of a larger federal fraud investigation into Sawyer and her husband. However, despite the blatant criminal financial interest, there has been no investigation of whether Sawyer may have unduly influenced Middleton’s decision to die.

In the UK, a former Director of Public Prosecutions for England and Wales, Max Hill KC, appeared at a news conference alongside Kim Leadbeater MP (the sponsor of the English equivalent of McArthur’s bill) earlier this year, where he stated: ‘There is really very little point in scrutinising, and looking for ‘bad cases’, after the death has occurred. What is the point of an investigation, even a prosecution, after someone has been coerced into ending their life?’ It is astonishing to hear a former prosecutor question the value of investigating and prosecuting people following suspicious deaths, and it adds to the sense that the risks posed by assisted dying to vulnerable people are not being taken seriously enough by its supporters.   

One of us highlighted in written evidence to the committee that scrutinised the McArthur Bill that although the bill mentions the risk of coercion by another person, it ‘ignores other forms of coercion that also matter: pressure exerted by society or social conditions, and pressure caused when a person internalises negative ideas about themself or their condition.’ There is evidence from other jurisdictions of people choosing to die because of inadequate health or social care, or because they feel like a burden to others. This kind of internal coercion would be particularly difficult to prevent, or indeed detect.  

The new crime of coercing someone to end their life would only address one form of coercion, and only in the unlikely event that it became visible to health professionals or others, and there was a will on the part of the authorities to take action.

If the Assisted Dying Bill becomes law, many Scots will come under external and/or internal coercion to end their lives. Lengthy waiting times for treatment (and particularly for accessing mental health services); NHS staff shortage; an underfunded and under-resourced social care sector, a national housing emergency; a palliative care sector reliant on charity; a benefits system that penalises those it should be supporting, including older adults and disabled people – any one of these would be a more appropriate use of parliamentary time and public attention than ‘assisted dying’. Scotland’s limited financial and resources and skilled workforce should be focused on assisting people to live.

Coerced deaths are inevitable

Opening the Stage 1 debate on the Assisted Dying for Terminally Ill Adults (Scotland) Bill, its author, Liam McArthur, said that Holyrood ‘cannot continue to leave this issue in the “too difficult” box.’  Supporters of the current bill are clearly impatient to see legal change, but are in denial about the scale of the risk that vulnerable people will be coerced to die (which is only one of the risks posed by the bill, but surely the most serious). Indeed, assisted dying campaigners seem more concerned about the risk that family members might ‘coerce’ a loved one by trying to talk them out of ending their life (something most of us would regard as perfectly natural and relatable). Successive Scottish parliaments have been rightly reluctant to ‘open the box’ and release assisted dying into Scottish society, and our current MSPs should be similarly reluctant. Given the scale of abuse, the low rates of disclosure, and the fact that training, however thorough, cannot reliably detect coercion, it is inevitable that coerced deaths will result if the Assisted Dying Bill becomes law.