Prime Minister Andy Burnham has argued that parliament should wait before returning to assisted dying until palliative and social care are properly funded. His intervention comes before MPs are due to debate a new assisted-dying bill for England and Wales on September 11.
Public debate often centres on people with terminal illnesses who are experiencing unbearable suffering and want greater control over how they die. Burnham’s argument raises a wider question: can a choice be fully voluntary when access to palliative care, social care, suitable housing or practical support restricts the alternatives someone believes are available?
Supporters argue that failures in care should be addressed without indefinitely denying terminally ill adults an autonomous choice. Our comparative analysis of parliamentary debates in Canada and England and Wales nevertheless shows why the language surrounding that choice deserves attention.
Politicians sometimes present choosing when and how to die as an expression of independence, courage or dignity. Others suggest that avoiding dependence on relatives or public services can be part of behaving responsibly in later life. A 2025 ethical analysis argues that framing assisted death as both an autonomous choice and a social responsibility could create pressure on older people who need care.
This does not establish that requests are generally caused by poverty, pressure or inadequate services. But it does raise questions about how circumstances can shape a decision without amounting to direct coercion.
Different systems
Canada’s medical assistance in dying law, known as Maid, allows practitioner-administered and self-administered deaths, although every recorded Canadian Maid provision in 2024 was practitioner-administered.
The terminally ill adults (end of life) bill would create a narrower system in England and Wales. It would apply to adults with decision-making capacity who have an inevitably progressive illness or disease and are reasonably expected to die within six months. They would have to take the final action that causes their death themselves.
Suffering is not a separate eligibility requirement. The bill instead requires a clear, settled and informed wish, made voluntarily and without coercion or pressure from another person.
MP Lauren Edwards reintroduced the bill in June 2026 after the previous version passed the Commons but fell because it did not complete its Lords stages before the parliamentary session ended. Its second reading is scheduled for September 11.
Canada’s law also changed after its introduction. Following the Supreme Court decision in Carter v Canada, parliament legalised Maid in 2016 for adults with a grievous and irremediable condition, advanced irreversible decline, enduring intolerable suffering and a reasonably foreseeable natural death.
In 2021, parliament removed foreseeable death as an eligibility requirement. Canada now distinguishes between Track 1 cases, in which natural death is reasonably foreseeable, and Track 2 cases, in which it is not. England and Wales would not inevitably follow the same course, but Canada shows that eligibility rules and safeguards can be substantially revised after legalisation.
What Canadian evidence can show
Health Canada recorded 16,499 Maid provisions in 2024. Of these, 95.6% were Track 1 and 4.4% were Track 2.
The distribution across neighbourhood income groups was broadly similar to that of all people who died from natural causes. Track 2 recipients were slightly more likely than this comparison group to live in the lowest-income neighbourhoods. Compared with Track 1 recipients, they were also slightly younger and more likely to be women or live alone. More lived in neighbourhoods with high residential instability.
These area-level measures do not reveal an individual’s income, housing conditions or reasons for requesting Maid. They cannot establish whether disadvantage contributed to a particular decision.
An Ontario chief coroner’s committee examined three deliberately selected Track 2 deaths involving possible social or structural vulnerability, including isolation, unsuitable housing and inadequate support. The committee stressed that the cases were not representative. They show the questions unmet needs can arise during an assessment without indicating how often these circumstances occur.
Practitioners reported that 74.1% of all recipients had received palliative care, compared with 23.2% of Track 2 recipients. The groups had different illnesses and proximity to death, and the figures do not establish whether available care was appropriate or adequate.
Small qualitative studies show that bereavement experiences vary. Interviews with nine people found that knowing the date of death could allow farewells and family rituals while creating an emotionally intense countdown. A separate study of 12 people who had experienced disagreement around Maid, documented unacknowledged pain and disenfranchised grief. Neither study shows how common these experiences are.
Choice and social circumstances
Our analysis suggests that praising assisted death as inherently brave or dignified risks creating an implicit contrast with people who continue to need care. Treating avoidance of dependence as socially responsible may reinforce fears of becoming a burden.
The England and Wales bill requires two doctors and a review panel to assess eligibility. Doctors must examine relevant records, make inquiries of health and social care professionals where appropriate, and discuss available treatment, palliative care, hospice care, symptom management and psychological support.
These are substantial safeguards. The bill does not, however, list an applicant’s reasons or unmet social needs as separate eligibility tests. Nor does it expressly require assessors to decide whether inadequate care or housing has narrowed the alternatives the applicant believes are available. A person may feel like a burden even when nobody has pressured them directly.
Reliable monitoring would therefore need information about applicants’ circumstances, access to care and reasons for requesting assistance. Canada’s data shows how difficult it is to assess inequality when official records rely heavily on neighbourhood measures and contain limited information about unmet needs.
Personal choice remains central to the case for assisted dying. Parliament should also consider how care shortages, isolation and fear of dependence may shape that choice before changing the law.
Christopher Lyon receives funding from a Leverhulme Trust Research Centre—The Leverhulme Centre for Anthropocene Biodiversity, grant no. RC-2018-021, the Biotechnology and Biological Sciences Research Council, grant number BB/Z516697/1, and the European Research Council. He has previously received funding from the York Environmental Sustainability Institute; the White Rose University Consortium; the Biotechnology and Biological Science Research Council, Economic and Social Research Council, Natural Environment Research Council, and the Scottish Government, grant no. BB/R005842/1; and the Social Sciences and Humanities Research Council of Canada, grant no. 132726. He has provided lived experience and research evidence to the Parliament of Canada’s Special Joint Committee on Medical Assistance in Dying.
Bethany Simmonds and Hermanpreet Singh do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
