Interim Report – Review of the Draft Assisted Dying Legislation

Interim Report – Review of the Draft Assisted Dying Legislation

Assisted Dying Review Panel

14 January 2026 [S.R.1/2026]

Background

The Assisted Dying Review Panel (the Panel) launched its review of the Draft Assisted Dying Legislation in September 2025. Since then, the Panel has undertaken extensive work to ensure a thorough and balanced assessment of the proposed law.

To date, the Panel has:

• Appointed three expert advisers to examine the ethical, legal, and academic implications of the draft legislation.

• Engaged with over 50 stakeholders, including professional and regulatory bodies, healthcare providers, medical experts, legal professionals, insurance and financial services, charities, and elderly care and residential services.

• Sought views on key issues such as safeguarding and ethical considerations, public awareness and accessibility, and financial and resource implications.

• Held a public hearing with the Minister and conducted numerous meetings to critically analyse the draft legislation.

Following the advisers' report and detailed analysis, the Panel is considering up to 15 potential amendments, which will require further consultation with experts. The Panel's full and detailed report will be published ahead of the debate. Despite working to a challenging timeline, the Panel has completed a significant volume of research and engagement.

We are publishing the expert advisers' report below to provide transparency and help the public understand the complexity and rigor of this review. Our aim is to build confidence that any Assisted Dying legislationand the services it enableswill be implemented to the highest standards, ensuring ethical, safe, and sensible practice.

The Advisers

The Panel sought to appoint expert advisers to provide independent analysis of the Draft Assisted Dying Law. A rigorous process was undertaken to identify leading experts in the field, including interviews with potential advisers to ensure breadth of expertise and relevance to the Panel's work. Following this process, three expert advisers were appointed.

• Dr Alexandra  Mullock is a Senior Lecturer in Medical Law at the University of Manchester. Her research interests include end-of-life law and ethics, reproductive law

and ethics, and the role of the criminal law in relation to harmful medical misconduct. Alex has undertaken policy and engagement work on assisted dying, supporting the Government of Jersey and Nuffield Bioethics Council Citizen's Juries, co - authoring the Ethical Review of the proposed Jersey law in 2023, and giving oral evidence

to the Health and Social Care Committee on Assisted Dying (2023) and the Committee

on the Terminally Ill Adults (End of Life) Bill 2024-25. Dr Alex Mullock is also Co-Editor in Chief ofMedical Law International.

• Professor Suzanne Ost is based in the School of Law at Lancaster University. Suzanne's areas of research expertise include the law and bioethics on assisted dying, exploitation in the doctor-patient relationship, the impact of criminal law on bioethics and health care practice, and unknowing victims of crime. Suzannewas Expert Adviser to the Jersey Citizens' Jury on Assisted Dying in 2021 and a Critical Friend to the Nuffield Council on Bioethics' Citizens' Jury on Assisted Dying in the UK in 2024. Her research has been externally funded by the Arts and Humanities Research Council and

the British Academy. She provided written evidence to the Committee on the Terminally

Ill Adults (End of Life) Bill 2024-25 and was the Editor in Chief of the Medical Law Review between 2011-2020.

• Professor Nancy Preston is a Professor of Supportive and Palliative Care and Co - Director of the International Observatory on End-of-Life Care at Lancaster University. Her research focuses on enhancing palliative care across all care settings. She leads international studies examining the experiences of healthcare professionals and bereaved family carers involved in assisted dying services in countries where such practices are legal. She advised the Nuffield Trust on its report exploring international models of assisted dying. She has also provided evidence to the Health and Social Care Committee on Assisted Dying (2023), the Committee on the Terminally Ill Adults (End of Life) Bill 2024–25, and the Irish Government's Select Committee on Assisted Dying (2024).

The appointed expert advisers have produced the attached report, which sets out their analysis of the Draft Assisted Dying Law, together with their findings and recommendations. Following expert advice, a small number of redactions have been made to the report relating to the names of medications that can be used for an assisted death and dosages.

ANALYSISOF DRAFT ASSISTEDDYING( JERSEY) LAW(P.65/2025)

Prepared for Jersey's Assisted Dying Review Panel by Suzanne Ost  I Alexandra Mullock  I Nancy Preston

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Table of Contents

AUTHORS .................................................... 5

BACKGROUND ................................................ 6

EXECUTIVE SUMMARY ......................................... 8

LIST OF RECOMMENDATIONS ................................... 10

THE INCLUSION OF TWO DIFFERENT MODES OF ASSISTED DYING: SELF- ADMINISTRATION OF THE APPROVED DRUGS BY THE PATIENT, OR ADMINISTRATION BY AN ASSISTED DYING PRACTITIONER .................................... 16

ASSESSING THE SAFEGUARDING STRUCTURES WITHIN THE PROPOSED LAW...... 19

1. Does the proposed Law outline sufficient and appropriate safeguards against coercion? .......................................................................................................... 19

1. The decision criteria element that the person's decision is voluntary and the challenge of identifying coercion................................................................. 19
2. The burden self-perception.................................................................... 22
3. Vulnerability to being coerced into requesting an assisted death .............. 24

4. Identifying coercion: Training and guidance for assisted dying practitioners and all on-island health and care professionals to accompany the draft law ........ 27
5. Protection against coercion offered by the draft law's request to proceed' arrangements ................................................................................................. 31

6. The additional safeguard in the draft law of a witness who knows the person well enough to consider that the person's request is voluntary ............................ 32

2. Alignment between the draft law and adult safeguarding structures .............. 33

3. Protecting and supporting those people with learning disabilities and considering the implications of the draft law for those with disabilities ............ 36

1. Independent advocates and independent advocacy regulations and safeguards for those with learning disabilities .................................................... 36
   2. Considering the implications of the draft law for those with disabilities ............ 38

4. Capacity ........................................................................................................ 40

1. Capacity test ........................................................................................ 40

2. Waiving the requirement for future capacity otherwise required at final Step 7 in the process and how this compares to other jurisdictional laws where it is permitted to provide assisted dying to individuals who have lost capacity ............ 42

2. Waiving the requirement for future capacity: remaining questions regarding capacity ......................................................................................................... 49

3. Where a waiver is in place but the person shows signs of refusal or resistance ...................................................................................................... 51

4.  Ensuring that the individual makes an informed decision ........................... 53

6. Providing information, continuing ongoing support, care and treatment for the individual whilst requesting an assisted death and on the assisted dying process, and supporting their family members and loved ones ....................................... 55

1. Providing information................................................................................ 55
2. Providing support ..................................................................................... 57
3. The care navigator role under the draft law ................................................. 59

7. Sharing of fitness to practice information with the GMC and other professional regulators ......................................................................................................... 62

8. Potential public protection gap: Professional bodies' investigation of health care professionals working for the Assisted Dying Service: suspensions and removal from professional register.................................................................... 63

CRIMINAL LAW OFFENCES ................................................................................... 63

1. Coercion offence ....................................................................................... 65
2. Other criminal offences ............................................................................. 66

APPEALS............................................................................................................... 68

1. On the health criteria decision ................................................................... 68
2. Appeal by a person with a special interest against a positive decision ........ 68

NO FEES FOR ASSISTED DYING SERVICE, POSSIBLE FEES IN THE FUTURE AND EQUITY OF ACCESS .............................................................................................. 70

MEDICAL ASPECTS ............................................................................................... 70

1. Training ...................................................................................................... 70
2. Matters relating to assessing capacity........................................................ 73
3. Terminal illness .......................................................................................... 74
4. Assessment of prognosis ............................................................................... 77
5. Assessment of expected suffering ................................................................. 78
6. Mode of administration: Implications for assisted dying practitioners ........... 79

4. Setting out the system of administration and roles in the Assisted Dying Service.............................................................................................................. 80
5. Staff refusal ............................................................................................... 80

6. Protection to health professionals who refuse to participate from employment detriments ................................................................................... 83

7. Clarification on need not to act to preserve life' after the approved drugs have been administered .................................................................................... 84
8. Place where the assisted death takes place ............................................... 84
9. Review ....................................................................................................... 85

PROPOSED END-OF-LIFE CARE LAW AND THE PALLIATIVE AND END OF LIFE CARE STRATEGY ............................................................................................................. 85

1. Proposed End-of-Life Care Law .................................................................. 86
2. Palliative and End of Life Care Strategy ....................................................... 89

1. Strategy Outcomes ............................................................................... 90
2. Funding ................................................................................................ 91

CROSS-BORDER IMPLICATIONS ........................................................................... 91 DOES THE DRAFT LAW ALIGN WITH HUMAN RIGHTS LAW? ...................................  92 CLARIFICATIONS .................................................................................................. 98 TABLE OF LEGISLATION ....................................................................................... 100 REFERENCES AND RESOURCES ......................................................................... 102

......................... 110

. ............................................................................. 110 ................................ 110

...................................................................................... 110

............................................... 111

...................... 111

APPENDIX 2: Two examples of possible frameworks for identifying coercion and undue influence in the academic research ......................................................... 112

APPENDIX 3: Example of a coercion offence that includes inducing someone to revoke their assisted dying request..................................................................... 114

AUTHORS

This report was prepared by:

Professor Suzanne Ost, Professor of Law, School of Law, Lancaster University, UK.

Dr Alexandra Mullock, Senior Lecturer in Medical Law, Department of Law, University of Manchester, UK.

Professor Nancy Preston, Professor of Supportive and Palliative Care, Division of Health Research, Co-Director of the International Observatory on End-of-Life Care, Lancaster University, UK.

Alexandra Mullock and Suzanne Ost previously advised the Jersey Citizens' Jury on Assisted Dying that published its recommendations in September 2021. Alexandra Mullock was one of three authors of the subsequent ethical review on assisted dying for the Jersey Government.

This report has been completed through the combined effort and expertise of the authors. All authors contributed to the background research for this Report. Suzanne Ost collated the report, and all authors drafted, reviewed, and edited specific sections, with Alexandra Mullock and Suzanne Ost taking shared lead responsibility for the legal and ethical aspects and Nancy Preston taking lead responsibility for the medical aspects and proposed end-of-life law and strategy aspects.

BACKGROUND

In November 2021 the States Assembly agreed, in principle, that assisted dying should be permitted in Jersey (P.95/2021). However, following an amendment (P.95/2021): Amd) to the proposals, the States Assembly also agreed that prior to the preparation of the law drafting instructions, detailed final proposals, to include all processes and safeguards on assisted dying, should be brought back to the Assembly for debate. The debate in November was informed by recommendations of the Jersey Assisted Dying Citizens' Jury. At the end of the Jury process, 78% of Jury members agreed that assisted dying should be permitted in Jersey.

In 2022, Islanders were invited to take part in the first phase of public engagement on the proposals. A summary report was published in May 2022 that identified the key themes to consider in the development of detailed proposals to focus on during the second phase of consultation.

Following elections in June 2022, a 12-week consultation period took place, which, alongside further delays due to the complexity of the subject, pushed back the debate in the States Assembly. A second consultation period took place between the 17th October 2022 - 14th January 2023 which resulted in a Consultation Feedback Report which was published on 28th April 2023. In June/July 2023, the Council of Ministers agreed and updated the proposal which informed an external Assisted Dying in Jersey Ethical Review report, published on 7th November 2023.

The proposals were debated in the States Assembly in May 2024. Due to the expansive nature of assisted dying and the extensive consultation work already undertaken by Government, the Assisted Dying Review Panel agreed to focus its scrutiny on assessing the final proposals for assisted dying in relation to the previous body of evidence received to date from experts and stakeholders. The Panel conducted the Review and produced a Report published on 14th May 2024 where a number of findings and recommendations were made. The Minister for Health and Social Services provided a Ministerial Response to the Report which accepted all four of the key recommendations, accepted 10 of the 12 recommendations and partially accepted 2.

Following the debate on the Proposals, the Review Panel continued to receive updates from Government Officers regarding the progress of the law drafting. A Review Panel Member attended the Health and Social Security Panel's Quarterly Hearing with the Minister for Health and Social Services on 20th May 2025 to ask questions relating to the Assisted Dying work progress. A transcript of the Hearing was produced.

The legislative proposals are due to be lodged (formally published) on 2nd September 2025 with a debate date of 20 January 2026. The Review Panel received an advanced draft of the Law, alongside key stakeholders, on 9th June 2025. The Review Panel launched its Review into the proposed Assisted Dying Legislation, examining the legal, medical, ethical and academic implications posed. The Review aims to ensure that appropriate and thorough scrutiny is undertaken to ascertain the robustness and transparency of the proposals.

The authors were thereafter contracted by the Review Panel to, inter alia, complete a report providing detailed analysis of the proposed Draft Assisted Dying (Jersey) Law 202- (P.65/2025), including the legal and ethical considerations of the proposed legislation, particularly regarding safeguarding and vulnerability. In addition, the authors were asked to review the alignment of the draft law with similarly modelled assisted dying laws in other jurisdictions.

EXECUTIVE SUMMARY

The following sections in this report address the areas of focus that we were asked to consider by the Assisted Dying Review Panel. In addition, we begin this report by addressing a further matter (the inclusion of the two different modes of assisted dying in the draft law), at the subsequent request of the Panel.

Assisted dying is not an easy subject. It is, of course, impossible to do justice to the

legal complexities and ethical challenges that assisted dying poses in one report and within a short time frame of ten weeks. A huge amount of work has gone into the drafting of Jersey's proposed law, and the legislative process and extensive consultation work

that preceded it. Our overall opinion is that the proposed law does meet the requirements and decisions made by the States Assembly sufficiently. Some amendments to the principles set out by the States Assembly through the adoption of P.18/2024 were made to the draft law. However, these are minor amendments, almost exclusively concerned with making the law safer and closing gaps to make the law workable. We have considered the more significant changes throughout our report

when such a change has related to one or more of the legal or ethical issues that we

have examined.

We were also asked to consider whether the proposed law aligns with international best practice. In addressing this aspect of our remit, we have referred throughout our report to laws that bear important similarities to the model of assisted dying under the draft Jersey law on key issues, where relevant. In so doing, we note parity or contrasting approaches and we specify whether, in our view, the alternative approach offers a more appropriate way forward.

In this report, we have identified issues that require additional scrutiny because of the legal and/or ethical questions that they raise. These form the basis of our discussion and recommendations. The key issues are as follows:

• Protection against coercion – the importance of the training and guidance for assessing doctors providing a clear explanation of coercion in the context of assisted dying, and setting out how to identify coercion/undue influence/pressure.

• Ensuring that the implications of the law's operation for Islanders with disabilities are closely monitored.

• That the draft law's assumption of capacity for making a request for assisted dying is post- rather than pre-assessment and is thus different than the presumption of capacity under the Capacity and Self-Determination (Jersey) Law 2016.

• The flexible approach to terminal illness, which allows people to refuse treatments that could extend life, raises the possibility that people with treatable conditions may be eligible. This may be intended by the States Assembly, however, since they voted to reject Route 2 (eligibility based on unbearable suffering in the absence of a terminal illness) in May 2024, it might be the case

that the States Assembly would prefer to have a more restrictive definition under the health criteria.

• The complexities and challenges regarding the waiver of future capacity; the proportion of practitioners who would be willing to administer the approved

drugs in waiver cases; and whether there is clear public support for the waiver.

• The relevance of speaking to an end-of-life/palliative specialist (nurse or doctor) in order for a person who requests an assisted death to be fully informed of end- of-life and palliative care options.

• The appeals process potentially allows a third party veto. This raises the possibility of an Article 8 ECHR challenge for violating the rights of a person with mental capacity, and so the panel and the States Assembly should be aware of

this issue.

• Consider the choice of the drugs used for self-administration, which in Switzerland are different to Oregon, and result in a quicker death.

• Consider the need to train clinicians in discussing both self-administration and medically administered assisted dying with the patient, as self-administration is likely to have less impact on the health care providers.

• On the proposed end-of-life care law, whether it would be more aspirational to adopt a palliative and end-of-life law and whether the proposed law should be a specific as it is.

• On the proposed end-of-life strategy, whether the prescriptive nature of the

Living Well model raises concerns about flexibility if future evidence suggests alternative approaches.

Throughout, we have emphasised key points by placing them in bold and placing questions in bold and italic font. Our recommendations are provided in one complete list at the outset. Each recommendation then appears contextually, at the end of each relevant section or sub-section.

We would like to acknowledge the assistance and support that we have received whilst undertaking our advisory roles from Kaya Camara (Acting Committee and Panel Officer, States Greffe) and Amelia Cushion (Research and Project Officer, States Greffe). They have both provided us with the necessary documentation and responded to our queries with patience and due diligence. Because we have been working within such a short time frame, it has not proven possible to receive information on one outstanding issue that we were still awaiting a response on at the time of the submission of our report. This is the current stage of the Jersey adult safeguarding law that is in development.

LIST OF RECOMMENDATIONS

1: To consider whether the draft law should also require that the Assisted Dying Assurance and Delivery Committee be under a statutory duty to give due consideration to:

1. models of good practice for training on coercion in jurisdictions where assisted dying is permitted; and
2. what the Addendum sets out as matters to be included in the guidance on coercion for the assessing doctors, assisted dying practitioners and all on - island health and care professionals; and
3. ensuring that the indicators of coercion in the training and guidance draw attention to:

1. the more subtle ways that coercion can occur in the assisted dying context to clarify understandings of coercion, the scope of undue influence and to help detect hidden coercion; and
2. the potential intersection between domestic abuse, financial and

coercive control, and vulnerability to coercion in the context of

assisted dying (p.30)

2. In line with best practice elsewhere, to consider whether to reinforce the duty to safeguard adults at risk by:

1. including a statutory duty in the draft law or a principle (see recommendation 2.ii directly below) requiring any health and social care professional involved in assisted dying to have regard to the need to protect individuals who are experiencing (or at risk of) abuse.  
2. This recommendation could be addressed by including the requirement to have regard to the need to protect individuals who are experiencing (or at risk of) abuse within a set of principles that reflect the five safeguarding objectives of the draft law. This could be achieved by having a provision set out in a similar way to section 3 (Principles to be applied') of the Capacity and Self-Determination (Jersey) Law 2016. (p.35)

3: That serious consideration be given to:

1. adding an article in the draft law that would require the establishment of a Disability Advisory Board to report on the implementation of the law and implications for disabled Islanders; OR,
2. if more appropriate for Jersey, adding an article to the draft law that would stipulate that there should be official representation from Islanders with disabilities in decision-making during implementation of the law, and reviewing the operation of the law post-implementation. (p.39)

4. To ensure the feasibility of the implementation of the waiver of future capacity, because the proportion of practitioners who would be willing to administer the approved drugs in cases where a waiver is exercised was not identified through the survey conducted in early 2025, there should be a further survey to ascertain this. (p.48)

5: That it be ascertained (if it has not been ascertained already), that there is clear public support for a waiver of future capacity and final consent. (p.48)

6: It should be made clear in the draft law that registered assisted dying practitioners who are willing to be administering practitioners can choose to refuse to be an administering practitioner where a waiver of future capacity is in place. (p.48)

7: The draft law should stipulate that if a registered assisted dying practitioner is not willing to perform an assisted death where there is a waiver of future capacity, they should make this clear at Step 6 when such a waiver is exercised, so that appropriate planning is possible. (p.48)

8: That the training for administering practitioners covers the practical complexities of the waiver of future capacity and final consent. (p.49)

9: As decision-making capacity is decision-specific, the draft law should require that the assessing doctors assess the person based on the capacity to waive the requirement for final consent decision at Step 6. (p.51)

10: That the draft law should clarify whether the approach to the assumption of capacity to waive the requirement for future capacity will mirror the same process as for the assessment that the person has the capacity to decide to end their life by assisted dying. In other words, the assumption can only be made provided that the doctor/practitioner finds no evidence of a lack of capacity to make a decision to waive the requirement for future capacity whilst making their assessment. (p.51)

11: That the draft law or guidance for assessing doctors should stipulate what the effect will be on the waiver of the requirement of future capacity if the individual still has capacity on the date set for the occurrence of the assisted death and wishes to pause the assisted dying process. It should also be specified whether, in this event, a new waiver would be required. (p.51)

12: Ensure adequate training is given to assess what constitutes a refusal of administration and consider if any tools currently used with non-verbal people are appropriate. (p.53)

13.i: That, in order to be fully informed of end-of-life and palliative care options, there be an additional requirement within the draft law that the person must have spoken to an end-of-life/palliative specialist (nurse or doctor) prior to the assessing doctor confirming their eligibility for assisted dying;

OR

13.ii: That, in order to be fully informed of end-of-life and palliative care options, there be an additional requirement within the draft law that the person be offered the option to explore all palliative care options with an end-of-life/palliative care specialist (doctor or nurse) prior to the assessing doctor confirming the individual's eligibility for assisted dying. (p.55)

14: Check the capacity of current bereavement services and whether those working for these services would be willing to take on this role for assisted dying, unless the costed-for bereavement services are to be provided within the Assisted Dying Service or through an alternative provider. (p.59)

15: The draft law should require that the Assisted Dying Assurance and Delivery Committee be under a statutory duty to give due consideration to models of good practice on the appropriate experience and qualifications for the care navigator role in jurisdictions where assisted dying is permitted. (p.62)

16: There will need to be clear guidance available to the public on what a person would need to do in order to self-refer and have access to a care navigator. (p.62)

17: Consider whether the support for those who are assessed as not eligible for assisted dying should be provided by care navigators, to ensure that there are no gaps in the provision of this support. (p.62)

18: That the distinction between the offences under Articles 47 and 48 be clarified. (p.68)

19. Consider whether a third party right of appeal against a positive decision (Article 42(3)) should be included, given the possible Article 8 ECHR violation in respect of an interference with the autonomy of a person who has been assessed as having mental capacity. (p.70)

20: Broaden training to include issues for the wider team (not just the extended assisted dying team) on how to handle their feelings, maintain team cohesion etc. (p.72)

21: That the draft law stipulate that key professional regulatory bodies should be consulted on the training. (p.72)

22: That it be clarified whether the training should be renewed every three years, as stated in the report accompanying the draft law. If so, then this should actually be specified in the draft law. Alternatively, it may be considered that this matter is more appropriately dealt with by the Assisted Dying Assurance and Delivery Committee, so that the maximum period of time that can pass before training must be renewed can be amended more easily to keep in line with professional

standards and benchmarking.

Whichever is the preferred approach, there is an inconsistency that requires correction between statements that the intervals being left to the Committee to decide within the draft law and the Addendum, and the stipulated three years provided in the report accompanying the draft law. (p.72)

23: Training for assessing doctors should cover assessing capacity when it is not possible to speak to friends and family. (p.73)

24: Training for assessing doctors should cover ensuring that the patient is made aware that approaching some family members or friends can be helpful to fully assess capacity. (p.74)

25. Consider whether the flexible characterisation of terminal illness that allows treatment refusal should be restricted. Given that the States Assembly voted against allowing access for non-terminal conditions (Route 2) in May 2024, they may wish to consider a more restrictive approach that limits access to those with, for example, an inevitably progressive physical condition that cannot be reversed by treatment' (Terminally Ill Adults (End of Life) Bill). (p.77)

26: Add the additional wording based on the information available at the time' to Article 25, as suggested by the BMA. (p.78)

27: Ensure that the training for assessing doctors covers the lack of clarity in prognostication. (p.78)

28: Create an organogram for the whole assisted dying system and roles in the Assisted Dying Service. (p.80)

29: Remove clauses stating that the administering practitioner cannot refuse to administer approved drugs (themselves) to an individual if they previously agreed to do so, and that an assisted dying practitioner, a certifying doctor and a care navigator cannot refuse to participate on the basis that they have opted-in to be an assisted dying practitioner. Replace with:

i.a) A clause that requires that the patient should be informed that there is a

chance that the administering practitioner or witness may not feel able to conduct the death on the day; and

b) state in this new clause that, in the event of this occurring, every effort will be made to identify an alternative provider;

OR

ii: State in this new clause that, for practitioner-administered assisted dying, a second administering practitioner must attend to either act as the administrator or witness. (p.82)

30: Obtain feedback from all the relevant professional bodies regarding the issue of staff refusing to participate on the basis that they have opted-in to be an assisted dying practitioner. (p.82)

31: Reconsider whether the roles of a member of the Committee or the Review Panel should be included as examples of a role that is not participation in assisted dying (and so would not be covered by the right to refuse) under Article 37. (p.82)

32: Consider extending Article 38's protection to self-employed practitioners. (p.84) 33: Ensure adequate training is given to assess what constitutes a refusal of

administration and consider if any tools currently used with non-verbal people are appropriate. (p.84)

34. Consult with the Jersey ambulance service to clarify terminology of need not act to preserve life under Article 10(4) to remove any ambiguity. (p.84)

35: Develop training for care home staff, including managers. Training should include a focus on understanding that transferring people late can be distressing for residents, especially if they consider the care home to be their home. (p.85)

36: Consider including a review of all assisted dying requests (whether resulting in an assisted death or not) for the first three years. (p.85)

37: Clarify the scope of the proposed end-of-life care law – should the law cover only end-of-life care (thus the final year of life), or broader palliative care? (p.89)

38: Engage stakeholders - to obtain feedback from the Jersey Care Commission and other providers on proposed provisions under the end-of-life care law, if this has not already occurred. (p.89)

39: Make the proposed end-of-life law less prescriptive and more aspirational: consider WHO and IAHPC guidance about comprehensive integration. (p.89)

40: Consider broadening the Palliative and End of Life Care Strategy's focus from just place of death to place of death and care. (p.90)

41: Change the Palliative and End of Life Care strategy outcome 1 to People in Jersey who need palliative and / or end of life care will be seen and treated as individuals who are encouraged to be involved in shared decision making about their care which may lead to advance care plans'. (p.90)

42: That it be expressly stated in the draft law that UK-based doctors should not be asked to take on the assessment role/provide opinions or provide information with the express use for assisted dying, whilst based in the UK. (p.92)

43: Correct the wording in [145] of P.65/2025. (p.99)

THE INCLUSION OF TWO DIFFERENT MODES OF ASSISTED DYING: SELF-ADMINISTRATION OF THE APPROVED DRUGS BY THE PATIENT, OR ADMINISTRATION BY AN ASSISTED DYING PRACTITIONER

The Jersey draft law allows for both self-administered and physician-administered assisted dying, in accordance with P.18/2024, [1] on the basis that restricting assisted dying to self administration can significantly limit options for some individuals'. [2]

The Ethical Review undertaken in 2023 includes a discussion of the ethical issues underpinning the two modes of delivering assisted dying. [3] We provide a summary here of the key reflections on these two modes that are provided in that review:

1. There are reasonable arguments in favour of, and against, each mode (self - administration and practitioner-administration).
2. If the States Assembly considers the arguments about the two modes to be balanced, then it may judge it appropriate to provide for both modes in law, with patients offered the choice of mode. If the (or a) central goal of the proposed law governing assisted dying is to respect patient autonomy, then allowing patients

the choice of mode of assisted dying would also be consistent with this goal.

3. However, the States Assembly may prefer on balance to primarily allow for self - administration, and to reserve practitioner-administration for exceptional cases. Practitioner-administration seems to raise more concerns, in view of: reports of significant increases over time in those jurisdictions that allow this; potential impacts on the overall role of health care professionals; and the low number of cases in which patients withdraw their request when practitioners are involved in administration, when compared with the numbers of those who decide not to self-administer a prescribed drug. [4] Self-administration may therefore be the

more prudent approach. However, in view of concerns about equal access for

those who may physically be unable to self-administer, practitioner - administration could be reserved for these sorts of exceptional cases. [5]

Finally, the authors stated that if self-administration is to be allowed, then experiences elsewhere[6] suggest that the different drugs and methods used in different jurisdictions would need to be examined closely to ensure that the safest and most effective approach is adopted.

Notably, research [7] shows that in jurisdictions allowing practitioner-administered and self-administered assisted dying, the majority of people have a practitioner - administered assisted death. The three main reasons for this are:

1. the drugs are more likely to work
2. the person or family prefers a medicalised death
3. the person may not be well enough to self-administer.

According to evidence from Canada, where either option is available, on the preference for practitioner-administered assisted death:

MAID[8] was administered by a practitioner in nearly all cases. In 2023, MAID was self - administered in fewer than five instances. While self-administration of MAID is

permitted in all jurisdictions in Canada (except for Quebec), very few people have

chosen this option since 2016.' [9]

Similar evidence of higher practitioner-administered rates when both options are available exists in Australian states. [10]

Under the law in the state of Victoria, Australia, it is also possible for assisted dying to

be administered by a medical practitioner, but only where the patient is physically

unable to self-administer.[11] In 2024-25, according to Victoria's Voluntary Assisted Dying Review Board's Annual Report, [12] there were 142 permits issued for practitioner - administered assisted dying compared to 492 permits being issued for self - administered assisted dying. It is likely that fewer people are choosing the practitioner - administered option there because of the limitation of it only being available where the

patient is physically unable to self-administer. 13 It was stated at the Panel's meeting with Jersey's Minister for Health and Social Services in November 2025 that this approach was considered but rejected on the basis of consultation with health care professionals, who were concerned that it would not be straightforward to define physically unable'. [13] We note, however, that there is no evidence that reaching a clinical view about whether the patient is unable to take or digest the approved drugs has

proven challenging in Victoria as a system-level issue.

Article 10(3) of Jersey's draft law states that 'If the individual administers the approved drugs themselves, their family member or friend may help them to do so (for example,

by helping them to raise the drugs to their mouth)'. If the draft law were to be amended

to reflect the approach taken in Victoria, then, taken together with the existing Article 10(3), this would give individuals the choice of self-administration if they are physically able to self-administer with assistance and a family member is willing to help, or doctor - administered assisted dying if this is not the case. This would reflect reasons provided

by the Citizens' Jury in favour of allowing practitioner-administered assisted dying

besides self-administered assisted dying. [14] But as the data from Canada and other states in Australia suggests that practitioner-administered assisted dying is the preferred option by the majority, limiting the availability of practitioner - administered assisted dying to cases where the person is physically unable to administer the approved drugs themselves would be more autonomy-restrictive. Notably, autonomy was also a reason given in support of the availability of practitioner - administered assisted dying for the Citizens' Jury.[15]

At the Panel's meeting with the Minister for Health and Social Services in November 2025, it was confirmed by the Minister that limiting the availability of practitioner-administered assisted dying to cases where the person cannot physically administer would not align with the outcomes of the public consultation (support for enabling people to have the choice of mode of assisted dying).[16]

Little data exists on the time to death for self-administered assisted dying. Publicly available data is available from Oregon, [17] but this does not include all possible drugs more commonly used in Europe for self-administration. Researchers in Switzerland are currently collecting the data in the Exit (an assisted dying right-to-die organisation) databases in Geneva.

They have direct experience of using a cushion which the patient presses' with their chin for self-administration where

and the matter of coercion. For instance, in the State of Victoria, Australia, the legislation requires that the coordinating and consulting medical practitioners must be satisfied that the person is acting voluntarily and without coercion'. [18]

Case law from England and Wales provides an indication of what makes a decision voluntary and the circumstances when an individual's will can be overborne so that their decision is no longer voluntary. In Re T (Adult: Refusal of Treatment), [19] Lord Donaldson stated:

The real question in each case is "Does the patient really mean what he says or is he merely saying it for a quiet life, to satisfy someone else or because the advice

and persuasion to which he has been subjected is such that he can no longer think and decide for himself?" In other words, "Is it a decision expressed in form only, not in reality?"'

And in U v Centre for Reproductive Medicine, the President of the High Court, Butler - Sloss LJ paid consideration to whether the patient could have his will overborne so that the act of altering the form and initialling the alterations were done in circumstances in which [he] no longer thought and decided for himself.'[20]

One way in which a person's will may be overborne is through undue influence, which

has been described in the academic literature as consisting in unconscionable exploitation of influence',[21] and in case law from England and Wales as occurring where the influence has invaded the free volition of the [person] to withstand the influence'. [22] It has also been held that insidious and pervasive' influence can be undue without necessarily being malign in its intention'.[23]

Undue influence amounts to coercion, and it is especially relevant to concerns about ensuring a person's request for an assisted death is voluntary. As Belshaw has recently noted:

Check a dictionary and it seems that coercion involves force, threats, physical pressure and compulsion. But the widespread concern with assisted dying is about something subtler. It's about illegitimate influence – effective yet often disguised – on someone's actions.'[24]

Explanations of coercion are provided in some of the guidance that accompanies

assisted dying laws elsewhere. For instance, the practical guide to the law in Austria [25] refers to influence by third parties, such as psychological or physical pressure

exerted by relatives [that] precludes a free and self-determined decision'. A situation of pressure can be assumed, for example, if the essential motive for the decision clearly stems from a third party motive (such as emotional, economic, or financial interests).' [26] The assisted dying guidance for health practitioners in South Australia defines coercion

as persuading someone to do something by using dishonesty, force, or threats. The

term abuse is intended to include coercion.' [27]

A particular challenge is assessing at what point relational influence becomes pressurising/unduly influential or coercive.[28] It is difficult to conceive of a situation where a person in personal relationships with others is not influenced or affected in some way by the views of these others. [29] There is a continuum between, at one end of the scale, appropriate discussions that have some non-pressurising influence on the person and, at the other end, bullying or harassing the person into a certain choice. In the middle, there is a greyer area of what might be described as respectful persuasion' [30] that could become subtle' pressure. There will be a fine line between these degrees of influence.[31] Recent research also considers how relational influences may support, as well as undermine' a person's request for an assisted death. [32]

Ensuring that the person is not prevented from making a voluntary wish, that is freely made [and that] may be influenced by our love and concern for others' [33] (but not unduly influenced) and, at the same time, detecting more subtle exercises of pressure and

undue influence, will not be easy.

It is an important safeguard that the assessing doctors must talk to the individual about whether anyone has asked, coerced or pressured them, or they have felt coerced or pressured, to request assisted dying. It is, however, vital that the training and guidance to be provided provide a clear explanation of coercion in the context of assisted dying, and set out how to identify coercion/undue influence/pressure (see below).

2. The burden self-perception

Besides others' influence having a coercive effect on a person requesting an assisted death, there has been increasing concern [34] about the voluntariness of the person's decision being affected by a burden self-perception. [35] For patients towards the end of life, the perception that they are a burden on their relatives has been described in the academic literature as a culturally pervasive phenomenon' and a common concern for people with advanced disease'. [36] As noted by Buchbinder and Berens:

Unlike the other types, this type of relational influence does not render the patient a passive object of influence. Rather than capitulating to another's desires, the patient exercises agency in expressing their own desire to avoid a certain outcome (ie, being a burden). [37]

The burden self-perception can often be a reason for individuals requesting an assisted death in jurisdictions where assisted dying is permitted. In Oregon, for example, 46.6% of those who had an assisted death under the legislation between 1998-2024 identified burden on family/friends/caregivers as an end-of-life concern. [38]

It is thus important that health care professionals assessing eligibility for assisted

deaths are able to identify the relational influences on their patients' decision to access assisted dying, such as being a burden, financial difficulties, and the inability to

integrate into the community'.[39] According to the findings of Variath et al's scoping review, health care professionals in jurisdictions that permit assisted dying engage in in-depth evaluation of patients' values on life and death, physical and existential

concerns to help ensure that requests are voluntary and informed.' [40] Those assessing the voluntariness of the person's request for an assisted death will also need to be alert to how the burden self-perception can intersect with other factors, and that

its impact could be reduced (by positive influence) or exacerbated (by coercion) from relatives. In other words, careful consideration needs to be paid to the ways in which autonomous individuals are enmeshed in social relationships that may shape their decisions in implicit and explicit ways'.[41]

Highlighting the complexity of this, a systematic review[42] of nine studies involving 219 patients (most of whom had advanced life-threatening illnesses and required physical assistance for daily activities), found that the burden self-perception is not either static or temporary but a fluctuating "process" in complex balances among numerous

factors'. The authors thus conclude that it should be continuously explored'. [43] In another systematic review of fourteen qualitative studies, the individual nature of the burden self-perception is emphasised by the authors: The feeling of being a burden cannot be understood without considering patients' personal interpretation of their dependency or care needs, and hence it is also necessary to understand their biographical background.'[44]

This is especially important because, as we discuss in the following sub-section, provided that the person has capacity and there are no factors impacting on the voluntariness of their request, it is not necessarily the case that the autonomy of a person's decision to request an assisted death is undermined by the existence of the burden self-perception. [45]

3. Vulnerability to being coerced into requesting an assisted death

Defining what exactly vulnerability means and the impact that this has on

individuals is an often imprecise, intricate, multifactorial process.[46] Traditionally, vulnerability has been framed as an exception to self-determining, autonomous and independent individuals. Some of the academic literature expresses an important

caution about applying blanket labels of vulnerability to certain groups in society;

assuming that individuals are vulnerable simply because they are disabled and/or

elderly, for example, can be inappropriate and offensive. [47] However, the contemporary approach to vulnerability within the academic literature is increasingly concerned with

the conception of universal vulnerability, which views vulnerability as an inherent

human characteristic, emphasising the embodied qualities of the human subject within our social environment that give rise to inevitable dependence on others. [48] For example, Formosa proposes that for any person who has close familial relationships, deferential vulnerabilities' may exist, causing the person to defer to their loved ones' wishes

because they are monopoly providers of something that [they] need, namely, their love, affection, and friendship.'[49]

Drawing on the universal vulnerability thesis in the context of assisted dying, Ost and Biggs's suggested starting point is to recognise potential vulnerability, in order to highlight that, as well as the universal vulnerabilities that relate to the human condition, vulnerability has a more profound impact on some individuals than others. [50] This requires consideration of the situational context, the social and economic circumstances and the relational environment within which the person exists.

Mullock and Lewis have examined vulnerability to assisted dying more closely via a theory of vulnerability developed by Mackenzie, Rogers, and Dodds (as well as theories of autonomy that ground this approach to vulnerability). [51] They suggest that such an account is particularly pertinent to assisted dying because it recognises the conceptual and often practical entwinement of vulnerability and autonomy, whereas standard approaches to vulnerability at law and "universalising" conceptions of vulnerability commonly treat vulnerability and personal autonomy as conceptually opposed.

On this approach an individual may be considered to be vulnerable to assisted dying; when they lack capacity because of some mental disorder (i.e., inherent vulnerability), [52] and/or when they are at risk of being coerced or otherwise unduly influenced (i.e., situational vulnerability), and when they are at risk of having their autonomy increasingly curtailed, denied, or violated because of protection-oriented, paternalistic assisted dying policies (i.e., pathogenic vulnerability). [53]

Additionally, Mullock and Lewis consider the tendency to associate vulnerability to assisted dying with an individual being a burden on others or suffering from, for example, loss or loneliness as a result of personal circumstances. The problem here is that such an approach conflates vulnerability to assisted dying with reasons that could, in our view, rationally underlie one's autonomous choice to pursue assisted dying. A person who is situationally vulnerable and/or physically disabled or suffering from a somatic condition might experience an autonomous desire to access assisted dying in a way that is not coerced, shaped by malevolent forces, or undermined by their particular physical disability or condition, and so paternalistic constraints may represent an infringement that is not desirable or acceptable for that individual. In other words, and being mindful of our criticism of the universal approach to vulnerability, rather than assuming that all vulnerable individuals are necessarily vulnerable to assisted dying, we suggest that only those who lack capacity or whose decision-making is subject to undue external influence should be considered necessarily vulnerable to the dangers of lawful assisted dying.

The autonomy of an individual's choice to pursue assisted dying is not necessarily undermined by them experiencing the burden self-perception, or experiencing isolation or loneliness, provided that the individual concerned is not mentally incapacitated and their choice is rationally coherent with these motivating factors and their wider set of values, rather than, say, arising from coercion or manipulation. For that reason, it is important, as our characterisation of vulnerability above illustrates, and as we argue below, to frame vulnerability to assisted dying in terms of the risks posed to autonomous decision making.

The potential intersection between domestic abuse, financial and coercive control, and vulnerability to coercion in the context of assisted dying has been highlighted by victim support charities. [54] It is thus notable that Article 65 of the draft law requires that the training for assisted dying practitioners includes domestic abuse and whether someone has been coerced or pressured to do something, including coercive control and financial abuse.'[55]

Hopkins, Price and Etkind have suggested recently that frailty can also be a factor that can exacerbate vulnerability to requesting an assisted death because of the burden self-perception, which they refer to as internalised coercion':

Concerns about internalised coercion in frailty are supported by research that shows feeling a burden is linked to feelings of dependency, loss of function and frailty, and is associated with a wish to hasten death.' [56]

They assert that for individuals living with frailty, decision making is often relational rather than resting with a single individual'.[57]

The three instances of possible vulnerability to coercion selected for the hypothetical case studies accompanying the draft assisted dying law include some of the situational and relational contexts in which vulnerability might exist: being elderly and the care burden', a history of domestic abuse and inheritance considerations. [58] They are effective in identifying some of the circumstances in which an individual might be more susceptible to coercion. However, they do not explore these issues, including the burden self-perception, [59] in any depth. We expect that this detailed consideration

will be present in the case studies and the role-playing that will be part of the required training for assisted dying practitioners that we discuss in the following sub-section; this is essential, in our view.

See Recommendation 1 below, at the end of the next sub-section.

4. Identifying coercion: Training and guidance for assisted dying practitioners and all on-island health and care professionals to accompany the draft law

Given the challenges and complexities discussed above, it will be imperative that the draft law ensures that the assisted dying practitioners who assess the person are trained well in identifying coercion and pressure,[60] and that this training is updated regularly to reflect findings from the latest research and best practice. As we have noted earlier, the draft law requires that the mandatory training for assisted dying practitioners must include matters related to whether a person has been coerced or pressured, coercive control, domestic abuse and financial abuse. [61] The development and maintenance of this training is to be arranged by the Assisted Dying Assurance and Delivery Committee (the Committee). The Committee would have the power to require the Assisted Dying Service to develop, change and provide this guidance and to require that the Committee approve the training. [62]

In the Addendum to the draft law, it is noted that the exact training requirements cannot

be confirmed prior to the law's adoption because this would mean that if any

amendments are made to the draft law, this could impact the training requirements. [63] We agree that the actual statutory law is not the place to provide the detailed

specificities of the training requirements, given the need to ensure that training is

regularly updated to reflect any changes to professional standards and benchmarks: having flexibility is beneficial here. However, importantly, the Addendum does provide a response to the Panel's recommendation that the training requirements

comprehensively covering the identification of and prevention of coercion be set out, by providing additional information about the training requirements for assisted dying

practitioners, those who undertake specific roles, and for all on-island health and care professionals.

The required training for assisted dying practitioners will be delivered in groups, face-to- face, supplemented by digital online elements and will also include case studies and role playing. [64] Assessing doctors will receive additional depth/detail or practical training, part of which will be a specific training module on eligibility criteria and the voluntary nature of decision, including domestic abuse and coercion. [65] Training for assisted dying practitioners will include specific training for extended team members on the voluntary nature of decision and supporting assessing doctors with identification of possible coercion – including additional steps to take where this is suspected, e.g. onward referrals' [66]

In line with the statement in the Addendum that the exact training requirements cannot be confirmed prior to the law's adoption, no further information is provided on what this training will include. The Addendum also does not clarify whether there will a definition of coercion provided in the training or guidance. However, it does include more detail on what will be included in the guidance on assessing individuals for assisted dying, and this provides some essential indicators of possible coercion. In consultations with carers, family or friends present, these could include:  

• excessive deferment by the person to their carers, family or friends for answers, reassurance or explanation

• carers, family or friends talking over the person and answering on their behalf

• inconsistencies in the person's answers to questions about their suffering, illness experience or assisted dying in general

• inconsistencies between what the person says in private to the assessing doctor, and what the person says in the presence of others' [67]

It will also be important to draw attention to the more subtle ways that coercion can occur in the assisted dying context (noted above).

It is stated that there will be a potential requirement to talk with the person away from others to determine if there is potential coercion' and that this discussion could include questions such as:

• whether the person is feeling any pressure from others to request assisted dying

• If the person has any significant financial concerns or any concerns about their family after their death

• whether there is anything the assessing person needs to know that the person does not want their family to know

• How do their family member/friends who are aware of the person's request for assisted dying feel about it and whether they support their decision' [68]

The guidance will also set out a process to be followed where there are concerns around coercion and/or abuse and any such concerns should be discussed at an extended team meeting. [69]

In making a decision on whether an individual's wish is clearly expressed and settled, the guidance will set out that the assessing doctor must discuss the person's reasons for requesting an assisted death. This will require a full exploration of what has given rise to the request, including the fears, anxieties and their suffering and the person's understanding of the impact of requesting and having an assisted death, and why they think accessing assisted dying will address their fears/concerns. The assessing doctor will ask the person about how they reached their decision, including what or who may have influenced them.  

Significantly, there is specific focus on exploring the burden self-perception:

• This may include the assessing doctor requesting that another member of the extended team, for example the social worker, reviews with the person their current care package and explores additional options for supportive care or respite care.

• The assessing doctor should also seek to understand why the individual has raised this concern and what they mean by it. Some people may say they feel like they are a burden because they believe or know that their family members are struggling to support them at the end of their life, while others may use this to start a discussion about their struggles with their current situation such as their sense of burden or loss of dignity.

• Such comments should also raise a "red flag" to the assessing doctor to explore whether there may be any element of explicit or implicit coercion underlying the person's request for assisted dying' [70]

Any requests to pause the process, previous assisted dying requests or withdrawal of requests must be considered when assessing the settled nature of the individual's wish. [71]

In addition, guidance for all on-island health and care professionals on appropriate conversations with patients will detail actions to take, if the professional is concerned their patient is experiencing coercion and pressure in relation to their assisted dying request'. [72]

This additional information about the content of the training and guidance provided in the Addendum reflects what is set out in P.18/2024. [73]

There will be input into the training from experienced assisted dying practitioners from jurisdictions where similar laws regulate assisted dying, and Australia is given as an example in the Addendum.[74] Whilst the more extensive coverage of coercion in the training for assisted dying practitioners in the Australian states is not publicly

accessible, [75] there are some resources that are publicly accessible. For health practitioners involved in assisted dying in Victoria, for example, the publicly accessible resources include a short video [76] on coercion, which advises doctors to discuss the reasons why a person is requesting assisted dying in a meeting separate from their

carers and/or family for insights into why the person considers that assisted dying will address their suffering. If the person is requesting assisted dying because they are concerned that they are a burden on their family, the health practitioner is advised to explore their situation –including discussing other options for support or respite care. [77]

Assisted dying practitioners in Victoria are also advised that there be a meeting with the carer and/or family members present, and indicators of possible coercion that are provided in the Victoria guidance mirror those that the Addendum states will be set out in the guidance for health practitioners who participate in assisted dying:

• excessive deferment by the patient to carers, family or friends for answers,

• reassurance or explanation

• carers, family or friends talking over the patient and answering on their behalf

• inconsistencies in the patient's answers to questions from the doctor about their suffering, medical condition experience and voluntary assisted dying in general.'[78]

The questions that are suggested in the guidance for the medical practitioner to include in their discussion with the patient include:

• Are you feeling any pressure from others to request voluntary assisted dying?

• Do you have, or are there any, significant financial concerns?

• Do you have any concerns about your family after you die?

• Is there anything we need to know that you don't want your family to know?

• What about your family/friends (may include partners, spouse, children,

• parents, siblings)?

• Are they aware of your request for voluntary assisted dying?

• How do they feel about it?

• Do they support your decision?'[79]

The additional information provided in the Addendum about what the guidance on coercion for the assessing doctors and other assisted dying practitioners who are asked to provide a relevant opinion for the purposes of an assisted dying assessment will include is very important. It reflects the key concerns and identifiers of possible coercion according to the existing research and the best practice that we have been able to access. [80]

Recommendation 1: to consider whether the draft law should also require that the Assisted Dying Assurance and Delivery Committee be under a statutory duty to give due consideration to:

1. models of good practice for training on coercion in jurisdictions where assisted dying is permitted; and
2. what the Addendum sets out as matters to be included in the guidance on coercion for the assessing doctors, assisted dying practitioners and all on - island health and care professionals; and
3. ensuring that the indicators of coercion in the training and guidance draw attention to:

1. the more subtle ways that coercion can occur in the assisted dying context to clarify understandings of coercion, the scope of undue influence and to help detect hidden coercion; and
2. the potential intersection between domestic abuse, financial and coercive control, and vulnerability to coercion in the context of

assisted dying

5. Protection against coercion offered by the draft law's request to proceed' arrangements

The request to proceed' arrangements are designed to offer an additional series of safeguards to protect against coercion by making it necessary for the assessing doctors to consider the possibility of coercion at each step in the process. In light of the academic research findings discussed above, this repeated consideration will be an important aspect of this safeguard, provided that the need to consider the possibility of coercion at each step is reinforced in the training to be provided.

Whilst there is a minimum time period that must pass between the first request for an assisted death and completion of Step 1, and the occurrence of their assisted death of at least 14 days, [81] there is no stipulated maximum timeframe in order to ensure that the individual moves at their own pace through the assisted dying process. [82] Ensuring that there is no maximum timeframe is an important safeguard against the individual being pressured into moving through the process more quickly than they would wish. As there will be a final review by the Administering Practitioner at Step 7, to determine, in part,

that the person's wish to proceed is still voluntary, this will help ensure that their

request is enduring over a longer time period. Additionally, the report accompanying the draft law also refers to delay from the person as indicating underlying hesitancy that

would require examination. [83]

6. The additional safeguard in the draft law of a witness who knows the person well enough to consider that the person's request is voluntary

At step 4, the witness who signs the form recording the individual's request with the co - ordinating doctor or administering practitioner must state in the form that they know

the individual well enough to believe that the individual's request appears to satisfy [the voluntary requirement]'. [84] The requirement mirrors similar provisions under assisted

dying laws elsewhere. [85] Importantly, to help ensure that the witness does not have a conflict of interest, they cannot be the person's close relative or an assisted dying practitioner involved in the individual's assisted dying process', and must be unlikely to benefit financially or in any significant way from the individual's death (for example,

under the individual's will) and does not believe otherwise'. [86] This is also a valuable safeguard to help protect against coercion, provided that the person can find someone to undertake this role and is comfortable in disclosing their request for assisted dying to

a potential witness.

We consider the additional protection offered by the coercion offence in our section on criminal law offences below.

2. Alignment between the draft law and adult safeguarding structures

The draft law would operate alongside existing adult safeguarding structures in Jersey. Whilst Jersey uses the Care Act 2014 (England) for guidance and to inform its adult safeguarding approach, this Act does not actually extend to Jersey. However, adult safeguarding legislation is being developed.

The current procedural framework in Jersey is set out in the Arrangements to Safeguarding Adults at Risk of Serious Harm document, [87] which follows the principles of best practice and arrangements established to safeguard children. [88] It sets out the arrangements to realise effective adult safeguarding practice including the

responsibilities of Safeguarding Partners and Safeguarding Professional Leads to

ensure, inter alia:

• that frontline staff and supervisors have effective inter-agency policies and procedures to follow to safeguard adults at risk from serious harm, regardless of where that harm occurs (Safeguarding Partners).

• that systems are in place to ensure relevant information is shared between agencies to safeguard adults at risk, and quality assurance processes to

measure the effectiveness of the policies and procedures (Safeguarding Partners).

• that core multi-agency safeguarding processes are working well, with clear

line of sight to front line practice and there is an agreed programme for improving safeguarding outcomes (Safeguarding Partners).

• that they analyse and direct the real time picture of how effectively multi - agency safeguarding arrangements are working and alerting Safeguarding Partners of key challenges and emerging priorities (Professional Leads Group).

• that appropriate review mechanisms are initiated for serious adult

safeguarding incidents where the abuse or neglect of an adult is known or suspected, and the adult has died or been seriously harmed. This would be in the form of an initial Rapid Review of such cases to inform a decision about whether a Serious Case Review should be commissioned (Professional Leads Group and Safeguarding Partners).

• That they review data collection and data sharing across the safeguarding system to identify safeguarding needs and risks to target actions in priority

areas (Safeguarding Partners).

• The delivery and monitoring of multi-agency priorities and procedures to protect and safeguard adults at risk in Jersey, in compliance with published arrangements and thresholds (Professional Leads Group).

• That feedback from adults at risk about their experiences of services is sought and responded to, and safeguarding services are co-designed to ensure

adults at risk from different communities and groups can access the help and protection they need. [89]

Five priority improvement areas have been agreed by the Safeguarding Partners and the Professional Leads Group for each year of operation. The practice of safeguarding adults is supported and monitored by a structured set of subgroups and independent scrutiny is provided by the Independent Safeguarding Scrutineer, as part of a wider system of review which includes inspections from the Jersey Care Commission. [90]

The assisted dying training focused on coercion discussed above, will be an addition to existing mandatory safeguarding training on domestic violence and abuse for all health staff. [91] The Jersey Multi-Agency Adult Safeguarding Policy will also apply to protect people with care and support needs, who are experiencing (or at risk of) abuse or

neglect and are unable to protect themselves because of their care and support needs.'[92] Included in the categories and indicators of abuse within this policy are definitions of domestic abuse, controlling behaviour and coercive behaviour, [93] examples of emotional/psychological abuse [94] and financial abuse, and lists of possible indicators of both. [95] Whilst it is possible that an individual who requests an assisted death could be experiencing or have experienced any one (or more) of these forms of abuse, with coercion being of particular concern in the assisted dying context, we highlight the Policy's definition of coercive behaviour as including:

an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten the subject of the abuse.'

The Policy further states that All forms of domestic abuse involve perpetrators seeking to exert power and control over their partners or family member and often incorporate a range or variety of abusive behaviours.' [96]

The role that health care services can play in identifying domestic abuse and the vital need for this has been highlighted in a policy report assessing support services in England and Wales. [97] The same policy report has emphasised the need to provide specialist services for minoritised groups including Black, LGBTQ+, autistic or neurodiverse domestic abuse victims and survivors. [98]

Specialist training in coercive control and domestic abuse for any health care

professional involved in assisted dying has been called for by experts in domestic

homicide. [99] As we note above, this will be included in the training provided to

assessing doctors according to the draft law and the Addendum. [100] The Addendum also states that in the guidance for assessing individuals for assisted dying, if there is a

concern that the person may be experiencing coercion and/or family and domestic

violence, financial abuse or elder abuse, then these issues should be discussed with the individual. These concerns should also be considered at an extended team

meeting, and the assessing doctor must make a referral to the appropriate adult safeguarding team if there are any safeguarding concerns regarding abuse.[101]

We are satisfied that there is no misalignment between the safeguarding structures within the draft law and the current adult safeguarding procedural framework and policies that exist in Jersey. However, we note that in some jurisdictions that permit assisted dying, the duty to protect those who are experiencing

(or at risk of) abuse is reinforced in the assisted dying legislation. In Victoria, Australia, for example, one of the principles that any person exercising a power or performing a function or duty' under the Act must have regard to is that there is a need to protect individuals who may be subject to abuse'. [102]

Recommendation 2: In line with best practice elsewhere, to consider whether to reinforce the duty to safeguard adults at risk by:

1. including a statutory duty in the draft law or a principle (see recommendation 2.ii directly below) requiring any health and social care professional involved in assisted dying to have regard to the need to protect individuals who are experiencing (or at risk of) abuse.
2. This recommendation could be addressed by including the requirement to have regard to the need to protect individuals who are experiencing (or at risk of) abuse within a set of principles that reflect the five safeguarding objectives of the draft law. This could be achieved by having a provision set out in a similar way to section 3 (Principles to be applied') of the Capacity and Self-Determination (Jersey) Law 2016.

We have noted the concern that domestic abuse, financial and coercive control, and vulnerability to coercion could intersect in the context of assisted dying above. The existing mandatory safeguarding training on domestic violence and abuse for all health staff and safeguarding polices are thus highly important.

3. Protecting and supporting those people with learning disabilities [103] and considering the implications of the draft law for those with disabilities

(a) Independent advocates and independent advocacy regulations and safeguards for those with learning disabilities

Importantly, the draft law sets out advocacy support by way of independent advocates during the assisted dying process, to help individuals understand options for, or

aspects of, end-of-life or other palliative care or assisted dying or to convey the individual's views and wishes about them', for example. [104] It will be for the Regulations that would follow the enactment of the draft law to set out the procedure for appointing independent advocates, their required qualifications, etc. [105] These Regulations will also specify the criteria for a "qualifying person" who may be supported by an independent

advocate and the steps to be taken to ensure that a "qualifying person" who has requested assisted dying is aware of the availability of the services of independent advocates' and set out the matters that independent advocates can offer help with and the functions that they can undertake. [106] Whilst full guidance for independent advocates will be developed alongside the Regulations, the Addendum gives an indication of what this guidance is expected to include, such as how an assessing doctor/administering practitioner will:

• decide the communication support or advocacy requirements for the individual, and when additional relevant opinions may be required to reach a decision;

• arrange for communication support/advocacy for the individual considering factors such as: where a person may require more than one type of communication support and/or advocacy; where remote communication may be appropriate compared to when in-person support is required'[107]

Alongside this, the assessment guidance will detail considerations for assessing individuals with learning disabilities and/or autism spectrum disorders, including requirement to allow additional time for assessments (to accord with guidance on independent advocacy and communications support)'.[108] This reflects Priority 1 of the Disability Strategy for Jersey, that people with disabilities have support to communicate and access information'.[109]

It is expected that the guidance on independent advocates will cover circumstances in which it may be appropriate for a connected person (i.e. a family member) to provide communications support, plus associated benefits and risks'.[110] We note that the issue

of undue influence is relevant in the context of supported decision-making for people with mental disabilities, and this risk is highlighted in, for example, internal Health Care Jersey safeguarding policies that emphasise the need to carefully balance the

autonomy of those with learning disabilities with ensuring their safety. [111] In the academic literature, Craigie has cautioned that while a shift from substituted to supported decisions provides an opportunity for empowermentwith the person moving from decisions being made on their behalf to being the legally recognised decision-makerthis empowerment may be curtailed by the inappropriate involvement of a supporter.' [112]

It will thus be important that the training and guidance on coercion include this consideration of ensuring the independence of an advocate and address the risk of undue influence/coercion, especially where the proposed advocate is a connected person to the individual who has requested an assisted death. Provided this is the case, we consider these aspects of the draft law, regulations and planned guidance to be well-aligned with Jersey safeguarding policies that emphasise the need to carefully balance the autonomy of those with learning disabilities with ensuring their safety.[113]

b) Considering the implications of the draft law for those with disabilities

As part of its protection of people with disabilities' equal recognition under the law, the UN Convention on the Rights of Persons with Disabilities (UNCRPD)[114] requires that States Parties recognize that persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life' and take appropriate measures to provide access by persons with disabilities to the support they may require in exercising their legal capacity'.[115] Moreover, all measures that relate to the exercise of legal capacity should include safeguards to:

ensure that measures relating to the exercise of legal capacity respect the rights, will and preferences of the person, are free of conflict of interest and undue influence, are proportional and tailored to the person's circumstances The safeguards shall be proportional to the degree to which such measures affect the person's rights and interests.'[116]

Concerns have been expressed about the risks to people with disabilities in one of the written submissions from Dr John Stewart-Jones/Jersey Dying Well Group. [117] The submission includes the concern that a law on assisted dying that includes suffering as part of its eligibility criterion could give rise to a premise that if individuals with disabilities are suffering, it is legitimate for their assisted deaths to be enabled by the State in the absence of safeguards. [118] However, a person would only be eligible under the draft law if they have a terminal illness and, thus, we do not consider that the draft law gives rise to such a premise. Moreover, excluding terminally ill disabled people from being eligible under the draft law because of the fact that they are disabled would, in our view, fail to support people with disabilities' equal recognition under the law. Rather, it should be ensured that people with disabilities who meet the eligibility criterion and wish to request an assisted death are given the support that they may require in exercising their legal capacity, alongside safeguards that are proportional and tailored

to their specific circumstances.

There is one recommendation that we wish to make, however, to help ensure that, if the draft law is enacted, the implications of its operation for disabled people are closely monitored. The Terminally Ill Adults (End of Life) Bill requires the appointment of a Disability Advisory Board that must include, inter alia, people who have a disability under the Equality Act 2010 and representatives from disabled people's organisations. The Board would be required to report on the implementation of the Act within six months of its appointment and then annually thereafter on the law's operation and implications for disabled people. [119] It is stated in the report accompanying the draft law that the:

Jersey draft law does not require establishment of advisory board, but work [is] being undertaken with groups who represent disabled islanders regarding collaboration during the implementation period, and how to include voice of disabled islanders in

set up of Service.'[120]

However, we would argue that requiring the establishment of a Disability Advisory Board during the implementation period would emphasise the priority attached to ensuring that the law is not operating in a way that could have negative impacts on disabled Islanders. It would give formal recognition to a body that would include disabled Islanders and groups who represent them.

Recommendation 3: That serious consideration be given to:

3. adding an article in the draft law that would require the establishment of a Disability Advisory Board to report on the implementation of the law and implications for disabled Islanders; OR,
4. if more appropriate for Jersey, adding an article to the draft law that would stipulate that there should be official representation from Islanders with disabilities in decision-making during implementation of the law, and reviewing the operation of the law post-implementation.

4. Capacity

1. Capacity test

One of the five safeguarding objectives of the draft law [121] is to ensure that all islanders are protected and supported throughout the assisted dying process, and this includes people who do not have decision-making capacity.

The capacity criterion set out in the draft law stipulates that when the individual is assessed for assisted dying eligibility, they have capacity to decide to end their life by assisted dying. [122] Mirroring the capacity test under the Capacity and Self-Determination (Jersey) Law 2016 (CSDL), [123] but also making the test specifically relevant to the assisted dying decision, the doctor/practitioner must be satisfied that the person has

the capacity to:

(a) receive the information given to them under this Law about their decision or request;

2. understand the information and the matters relevant to their decision or request (including the effect of their decision or request);
3. retain the information for long enough to make their decision or request;
4. use or weigh the information and matters in making their decision or request; and
5. convey their decision or request (by any means).'[124]

Under the CSDL, as under the Mental Capacity Act 2005, [125] there is a (rebuttable) presumption of capacity,[126] which means that the doctor must presume that the person has capacity unless there is evidence that they do not.

There is also an assumption of capacity under the draft law: the doctor/practitioner must assume that the person has that capacity unless there is evidence that they do not'.[127] However, the draft law sets out a different, more nuanced version of the assumption of capacity than exists under the CSDL. The draft law requires that when the individual is assessed, they have capacity to decide to end their life by assisted dying'.[128] Importantly, the assumption of capacity is not made at the outset, on the basis that there is no evidence of capacity. Rather, the assumption of capacity can only be made provided that the doctor/practitioner finds no evidence of a lack of capacity whilst making their assessment. [129] In other words, the assumption of capacity is post- rather than pre-assessment.

This is a notable distinction that will require a change in the usual professional practice regarding the assessment of capacity. It will need to be ensured that this is reflected in the training provided to assessing doctors, [130] and it is therefore positive to see that the assessment guidance will include matters related to requirement

on assessing doctors to be satisfied as to the individual's capacity (i.e., cannot be presumed, must be determined)'. [131] Additional training modules that assessing

doctors will receive include one on assessing capacity [132] and, thus, we would expect to see this issue covered in this training module too.

It is a more diluted version of the assumption of capacity, in that whilst it demonstrates respect for autonomy, it only does so after no evidence of a lack of capacity can be found. It is thus less of a presumption and more of an assumption of capacity that must be confirmed, thereby reflecting the suggestion in the Ethical Review of removing the presumption in favour of capacity in the case of AD specifically, so that all applicants are routinely assessed'. [133]

There are ethical arguments against this move away from the usual presumption of capacity, because, in the context of a request for assisted dying, it reduces the automatic respect for autonomy enshrined in the law. Moreover, it would create an inconsistency in the law and medical practice between the approach to assuming capacity in relation to assisted dying requests and the approach taken for other end-of-life decisions. However, these arguments against adopting an assumption

of capacity that must be confirmed should be balanced against the additional safeguarding protection that this could provide for assisted dying decisions, by requiring the doctor/practitioner to be satisfied that they cannot evidence that the person lacks capacity.

Where the doctor cannot determine whether a person has capacity, they must seek the relevant opinions of others. [134] This is an important safeguard against error and reflects a recommendation within one of the individual written submissions that provision should be made for appropriately trained professionals to undertake [capacity] assessments

also.' [135]

(b) Waiving the requirement for future capacity otherwise required at final Step 7 in the process and how this compares to other jurisdictional laws where it is permitted to provide assisted dying to individuals who have lost capacity

The draft law provides that at step 6, after an individual's assisted dying request has

been approved (step 5), but before they make their final confirmation of consent during

the final review (step 7), the individual can opt to waive the requirement that they have future capacity. [136] They thus can make an advance decision that, if they lose decision - making capacity after step 6 but before step 7, their assisted death can still take place.

This provision extends respect for autonomy whilst the person has capacity, where the person's capacity will deteriorate rapidly.[137] However, it is not a provision reflected in almost all assisted dying laws elsewhere. One exception is the MAiD law in Canada, under which a waiver of final consent is permitted, [138] provided that:

• prior to their loss of capacity, the person met all the eligibility requirements;

• all procedural safeguards were satisfied;

• their natural death is reasonably foreseeable;

• the person was informed of the risk of losing capacity; and

• they completed a written agreement to receive MAiD on a specified day. [139]

The rationale for the existence of this provision under the Canadian law is to avoid some people requesting MAiD sooner than they would wish because of a concern that should they wait and lose capacity, they would no longer be eligible for MAiD. The law was amended to enable this through Audrey's Amendment', referring to the case of Audrey Parker, [140] who chose to receive MAiD earlier than she wanted because of this fear.

Although Canada's waiver of final consent provision was introduced in 2021, its implementation was slower, hence there is less data. The Fifth Annual Report on Medical Assistance in Dying in Canada 2023 identified that 594 assisted deaths invoked the waiver of consent out of 15,343 deaths – 3.87% of all assisted deaths. Most (73%) were conducted by the family practitioner, 13.1% by palliative care, and 5.1% anaesthetists. [141]

Under the Canadian law, it is common practice to establish a waiver between the person seeking MAiD and one provider, but it is not unlawful under Federal law to transfer to another provider. This is common in several States, but the alternative provider must be named and must have conducted an independent eligibility

assessment prior to the loss of capacity. They must also have discussed this with the individual and have their agreement. This may be thought of as multiple waivers of consent in one document.

The Jersey law does not seem to treat the waiver in the same (quasi contractual) way. Rather it sets out an approach where a person makes at statement (at stage 6) and the administering practitioner agrees.

Question: If the assisted death is then arranged to go ahead, can another administering practitioner administer the drugs, or must it be the administering practitioner who has previously agreed?

The Canadian approach also covers individuals who wish to take a sedative prior to receiving an assisted death to treat anxiety etc before the assisted dying practitioner arrives, and so capacity may be lost due to a choice to ingest sedative drugs rather than because of illness. [142]

Question: This scenario is not addressed by the Jersey draft law, and so should this be considered?  

In the Netherlands, Belgium and Spain, whilst there is no waiver of final consent provision in the assisted dying legislation, people can create advance decisions requesting euthanasia. In Belgium, this applies to cases where people are seriously injured in accidents (where they enter an irreversible, permanent unconscious state) rather than when a disease is expected to cause a loss of capacity, and so we do not include consideration of the Belgium law here. [143] In the Netherlands and Spain, however, the parallels with the advance decision to have euthanasia after a person with capacity has been assessed and eligibility has been agreed, are similar to the waiver of final consent confirmation and so it is useful to include this information.

In the Netherlands, assisted dying is regulated under the Termination of Life on Request and Assisted Suicide (Review Procedures) Act 2021. The law allows for euthanasia based on an advance directive from a person with capacity who meets the eligibility criteria, where, at a later point, the individual loses the capacity to make an assisted dying decision due to, for example, advanced dementia [144] or reduced consciousness

where there are signs that the patient is suffering. An advance decision can effectively serve as a waiver of final consent if the patient loses decision-making capacity. The parameters of the Dutch Law regarding advance directives are explained in a government source:

Key Points:

• A mentally competent person may write an advance directive requesting euthanasia.

• The directive can be used if the person later becomes incompetent (e.g., due to dementia or unconsciousness).

• The directive must clearly describe the conditions under which euthanasia should be performed.

• There is no prescribed format for the advance directive and the patient can write this in their own words, but they should discuss it with their physician

• The physician must ensure all legal due care criteria are met, including:

 The patient's suffering is unbearable and hopeless.

 No reasonable alternatives exist.

 An independent physician has been consulted.

 The procedure is medically appropriate.

• The patient must not show signs of resistance at the time of administration.

Limitations:

• The directive must have been written while the person was competent.

• The physician must be convinced that the patient's condition matches the directive and that euthanasia is ethically and legally justified. [145]

A Dutch case, the Mrs A case (also sometimes referred to as the coffee case') is the

only prosecution that we are aware of within any jurisdiction that allows practitioner - administered assisted dying to a person who has lost mental capacity. It illustrates the main ethical concern that such cases generate.[146] Mrs A, who suffered from dementia, had an advance euthanasia directive requesting euthanasia (AED) in the event of severe dementia. This had been made several years earlier. By 2016, she had lost capacity and was living in a nursing home. The doctor sedated Mrs A without her knowledge and proceeded with administering euthanasia. During the procedure, Mrs A physically resisted. Her family aided the doctor by restraining her. The doctor was prosecuted in 2019 because there were doubts about the validity of the AED. Questions emerged

about the specifics of the AED, whether Mrs A had mental capacity at the time she created the AED, and whether she was suffering unbearably (as the Dutch law

demands) at the time of the euthanasia. Also, there was no attempt to engage with the

patient's current wishes. This was flagged by the Regional Review Committee[147] and referred to prosecutors. In 2020, the Dutch Supreme Court acquitted the doctor on the basis that she had acted in accordance with the AED, because doctors should be permitted to act on a contextual interpretation of the AED even if the patient is unable to confirm consent at the time of the procedure. [148]

The law in Spain is the Ley Orgánica de regulación de la eutanasia (Organic Law on the Regulation of Euthanasia). The legalisation of assisted dying is quite recent and, thus, there is more limited information in the English language on the impact of the law or the way that the advance decision provision has been dealt with in practice.

Article 5 of the law explicitly allows individuals to submit an advance directive (known in Spain as a documento de instrucciones previas) requesting euthanasia in case they lose decision-making capacity. The directive must be:

• Written while the person is competent.

• Registered in the national or regional registry of advance directives.

• Clear about the conditions under which euthanasia should be administered.

It appears that there have not been any problem cases arising in Spain, but concerns

have been flagged over the specifics of the advance directives. [149]

Although the waiver of future capacity in the draft Jersey law is not an advance decision, and so has more in common with the approach in Canada rather than in the Netherlands or Spain, the legal effect of the final waiver is very similar to an advance decision and will face the same challenges regarding practitioner - administration to a patient who lacks capacity. As the Dutch case (Mrs A) illustrates, in jurisdictions allowing either an advance directive requesting euthanasia or final waiver of consent, the ethical and professional challenges of administering the drugs to

a patient who is not currently consenting are significant. Despite this, there is arguably a strong ethical justification for having a waiver of future capacity, on the basis that it avoids encouraging people who anticipate losing mental capacity to rush to receive assisted dying while they retain capacity. Instead, the waiver encourages people to live longer without losing their right to have the approved assisted death that they have chosen to arrange. This also promotes autonomy.

It may be worth noting that although the Jersey Citizens' Jury members were not asked about a waiver of final consent, they were asked about whether the law should include an advance directive to request assisted dying after losing capacity, with the following results:[150]

According to P.18/2024, The Phase 1 consultation feedback showed limited support for a waiver overall'. The report goes on to state that there was strong support from 83% of those who were supportive of the principle of assisted dying'.[151] However, whilst a large number of those in support of the principle of assisted dying expressed strong support for the waiver, this does not, of course, evidence support for a waiver of future capacity and final consent across the Island.

The panel may additionally want to consider that the proposed laws in the UK (Terminally Ill Adults (End of Life) Bill, Scott ish Assisted Dying Bill[152]) and in the Isle of Man [153] do not include a waiver of final capacity to consent or an advance directive for assisted dying. These three approaches all require people to retain capacity at all

stages.  

The draft law states that the administering practitioner may administer the approved drugs where the individual does not have capacity and has waived the requirement for future capacity, if the individual does not show any refusal of, or resistance to, the approved drugs' administration. [154] There is no data to suggest that any practitioners were unwilling to administer an assisted death with a waiver of consent in Canada, but this does not mean that this did not happen. As noted, the majority of these deaths

were brought about by family physicians. This shows that family practitioners were willing to invoke the death under the waiver of consent, and it is also likely to be GPs who would be involved as administering practitioners in these cases in Jersey, alongside nurses. 160 However, in Jersey, there is a small workforce pool and, whilst some GPs might be willing to be the administering practitioner, some of these GPs may not be willing to undertake this role in those cases involving a waiver. A key question is whether it is known what proportion of on-island health professionals would be willing to act as administering practitioners in cases involving a waiver?161

It was confirmed at the Assisted Dying Review Panel's meeting with the Minister for Health and Social Services in November 2025 that there was no specific question on a willingness to be involved in waiver of future capacity cases in the survey, but that there have been discussions with a Health and Care Professionals Working Group set up to communicate with those that will be directly affected should the Assisted Dying Law be adopted, and with assisted dying practitioners in other jurisdictions. [155]

It has since been confirmed further by the Minister that:

The issue of the waiver was discussed extensively during the policy development phase from an ethical perspective, i.e. the ethical challenges of a practitioner not being able to administer the approved drugs where that practitioner was satisfied that the person wanted to have an assisted death – in order to maintain control and dignity and / or release themselves from pain and suffering - but had lost capacity in days / hours before having that assisted death. This included discussions with assisted dying practitioners in jurisdictions where assisted dying is permitted - but there is no waiver - and the associated distress caused to loved ones, in addition to the person, of not proceeding to administration contrary to the understood and clearly expressed wishes of the person.' [156]

This extensive discussion and consultation offer some reassurance but does not confirm clear public support for the waiver of future capacity, or that there will be practitioners who would be willing to administer the approved drugs in cases where a waiver is exercised. It is also unclear whether there has been any consultation with assisted dying practitioners in Canada who have been involved in cases where there has been a final waiver of capacity.

We do know very few doctors in the Netherlands are willing to carry out euthanasia for someone with advanced dementia and lacking capacity, but who has an advance directive stating they want an assisted death once their condition becomes

unbearable. [157] The Supreme Court has ruled that the doctor can determine when suffering is unbearable, [158] and perhaps this is the issue rather than a lack of consent.

Whilst P.18/2024 did include the waiver of the final confirmation of consent at Step 7, it did not include waiving the requirement for future capacity to request to proceed from Step 6 to Step 7. The report accompanying the draft law explains that this could have unintended consequences for an individual who waived the capacity requirement at

Step 7, but who had lost capacity before requesting to proceed to Step 7.'[159] Thus, there is an operational reason for the draft law's extension from the waiver of the final confirmation of consent at Step 7 to a waiver of the requirement for future capacity to request to proceed to Step 7 (at Step 6): to legally recognise a waiver of final consent when otherwise it might not have been possible to do so, because the person's capacity has deteriorated rapidly before progression to Step 7.

In light of the States Assembly's vote to proceed with assisted dying legislation that includes a waiver of final confirmation of consent, we concur that this addition to P.18/2024 to extend the waiver to the requirement for future capacity to request to proceed to Step 7 is required to better enable the operationalisation of the waiver. However, the key safeguarding concerns relate to the practical challenges involved in acting upon a waiver of the final confirmation of consent.

Given these challenges, as has been noted by the Canadian Association of MAiD Assessors and Providers (CAMAP), Applying categorical legal language to the variety and complexity of medical conditions and circumstances is challenging.' As a consequence, There has been a variable evolution in practice with respect to the use of waivers of final consent' leading to CAMAP developing good practice guidance for assistors and emphasising that each situation [should] be assessed and carried out on

a case by case basis'.[160] This guidance is helpful in highlighting good practice and important points for consideration, and we return to it in our next sub-section.

Recommendation 4: To ensure the feasibility of the implementation of the waiver of future capacity, because the proportion of practitioners who would be willing to administer the approved drugs in cases where a waiver is exercised was not identified through the survey conducted in early 2025, there should be a further survey to ascertain this.

Recommendation 5: That it be ascertained (if it has not been ascertained already), that there is clear public support for a waiver of future capacity and final consent.

Recommendation 6: It should be made clear in the draft law that registered assisted dying practitioners who are willing to be administering practitioners can choose to refuse to be an administering practitioner where a waiver of future capacity is in place.

Recommendation 7: The draft law should stipulate that if a registered assisted dying practitioner is not willing to perform an assisted death where there is a waiver of future capacity, they should make this clear at Step 6 when such a waiver is exercised, so that appropriate planning is possible.

Recommendation 8: That the training for administering practitioners covers the practical complexities of the waiver of future capacity and final consent.[161]

2. Waiving the requirement for future capacity: remaining questions regarding capacity

It is important to recognise that because decision-making capacity is decision-specific (linked to the specific decision at the time it needs to be made' [162]), even if a person may have capacity to decide to end their life by assisted dying, it will still be necessary to

assess whether they also have capacity to understand what the waiver of final consent involves and weigh this information when making their decision. [163] It will thus be important that the assessing doctors assess the person on the basis of the capacity to waive the requirement for final consent decision at Step 6.

It would also be helpful to clarify whether the approach to the assumption of capacity to waive the requirement for future capacity will mirror the same process as for the assessment that the person has the capacity to decide to end their life by assisted dying. That is, the assumption of capacity can only be made provided that the doctor/practitioner finds no evidence of a lack of capacity to make a decision to waive the requirement for future capacity whilst making their assessment. [164]

At Step 6, the individual's preference for when their assisted death will take place must

be recorded in their care plan. [165] It is possible that an individual could still have capacity at Step 7 at the date set for occurrence of assisted death. At this point, they may not

wish to make the final request for their assisted death occurring on this date. It is clearly stated in the draft law that an individual can withdraw from or pause the assisted dying process at any point. [166] If they wish to pause the process, but also wish to still waive the requirement for future capacity, is it necessary for a new waiver of final consent

to be made, given that the date in the previously completed waiver will have passed?

The Addendum states that it is intended that the guidance for assisted dying administering practitioners will set out the circumstances where it is appropriate to delay the assisted death at step 7 and re-schedule for a future date. It provides

examples of this being where the individual does not have capacity and is showing possible signs of refusal or resistance', or the administering practitioner determines the individual has fluctuating capacity, for example as a result of the administration of pain medication'. [167] In cases where this occurs because of fluctuating capacity, it is intended that the guidance will set out that the process can proceed when it has been

rescheduled if:

the individual does not have capacity at the agreed time of the rescheduled assisted death but has regained capacity at times during the intervening period prior to the rescheduled date, and at those times they consistently expressed a wish for the assisted death to be carried out.'[168]

However, there is no detail provided about a situation where the patient retains capacity at Step 7 and does not wish to make the final request for their assisted death occurring on this date, but still wishes to waive the requirement for future capacity. This situation is specifically discussed, and the process set out, in Canada's CAMAP guidance:

If the agreed upon date arrives while the person still retains capacity, the waiver of final consent cannot be used. That is, they will have to be asked for express consent which they may give or deny. If they chose not to proceed but still want to do so at a later date, they may specify a new date for provision and enter into a new waiver.

A waiver of final consent has one specific provision date and, while it can be used before this date if the person has lost capacity, it cannot be used once the date has passed. If MAiD has not occurred by this date, a new waiver may only be established if the person retains or regains capacity. Health Canada guidance suggests that any change in date requires a new written agreement, not just a date change on an older agreement.

There may be some value in reviewing a person's wishes prior to the specified date, rather than waiting for the exact date itself, so as to avoid any inadvertent lapse of access to MAiD via a waiver.' [169]

CAMAP recommends that when invoking a waiver, the assistor should clearly document that all of the legal requirements have been met. [170]

Recommendation 9: As decision-making capacity is decision-specific, the draft law should require that the assessing doctors assess the person based on the capacity to waive the requirement for final consent decision at Step 6. [171]

Recommendation 10: That the draft law should clarify whether the approach to the assumption of capacity to waive the requirement for future capacity will mirror the same process as for the assessment that the person has the capacity to decide to

end their life by assisted dying. In other words, the assumption can only be made provided that the doctor/practitioner finds no evidence of a lack of capacity to make a decision to waive the requirement for future capacity whilst making their assessment.

Recommendation 11: that the draft law or guidance for assessing doctors should stipulate what the effect will be on the waiver of the requirement of future capacity if the individual still has capacity on the date set for the occurrence of the assisted death and wishes to pause the assisted dying process. It should also be specified whether, in this event, a new waiver would be required.

3. Where a waiver is in place but the person shows signs of refusal or resistance

According to the report accompanying the draft law:

As set out in P.18/2024, Article 9 of the draft law provides that the Administering Practitioner may not continue with the administration of the substance if the individual demonstrates a refusal or resistance to the administration by words, sounds or gestures (for clarity, reflexes and other types of involuntary movements, such as response to touch or the insertion of a needle, would not constitute refusal).' [172]

Furthermore:

In the event that compliance with the care plan does not result in the individual's death, the administration practitioner may take a number of actions - including administering more approved drugs or different approved drugs, or administering the drugs in a different way. This includes where the individual still has capacity to consent, where the individual provided consent to the continued carrying out of an assisted death and where the individual does not have capacity, but they waived the requirement for future capacity.'[173]

The provision that states that the administering practitioner must not proceed if the individual demonstrates a refusal or resistance by words, sounds, gestures etc seeks to avoid the scenario seen in the afore-discussed Dutch case (Mrs A). In the ethical

literature,[174] it has been argued that when such resistance is ignored and the euthanasia goes ahead after sedation and/or restraint - which has effectively been sanctioned due to the Dutch court's approach in accepting that a contextual interpretation of the AED is valid - there is a danger that the assisted dying practitioner is acting against the current wishes and interests of the person who has lost capacity.

The Jersey draft law avoids this risk by invalidating the advance decision when resistance is demonstrated, however, the burden placed on health care professionals may be significant and distinguishing between signs of refusal/resistance that are intended as such rather than being involuntary responses to contact, needle pain etc, by an individual who has lost capacity may be very challenging. The need for guidance and training to deal with this scenario is crucial.

Looking again to Canada, it is only possible to provide MAiD when the person does not demonstrate, by words, sounds or gestures, refusal to have the substance administered or resistance to its administration. [175] The addendum to Jersey's draft law states the

intent that the guidance will specify that the ability to refuse administration is retained when an individual lacks capacity. Any signs of refusal or resistance to the carrying out of the assisted death may include: refusal by words, sounds or gestures' and any

physical or verbal resistance to administration'. [176] However, signs of refusal/resistance are not considered to include involuntary words, sounds or gestures made in response to contact'. Such involuntary reactions to contact or insertion of a needle do not constitute a demonstration of refusal or resistance'. [177]

The ability to stop the assisted death is clearly set out. The justification for delaying or pausing the assisted death in order to try again another day, for example where there is fluctuating capacity, seems reasonable in terms of it not going ahead

unless the person regains capacity at the time of the assisted death and expressly consents, or gains capacity at a time before any rescheduling and expresses a wish for the assisted death to proceed. This approach is similar to the Canadian approach, but CAMAP expressly provides that such refusal/resistance permanently invalidates the waiver.[178] This means that assisted death may only proceed in the

future if there is a fresh request to proceed, either at the time of the assisted death or beforehand, in which case a new waiver of final consent is required.

The main challenge will be establishing whether any signs of resistance should be interpreted as a refusal, i.e., they appear to be voluntary and intended to prevent the assisted death despite the lack of capacity, or whether they are simply involuntary responses to contact and the pain of a needle etc, for example. The content of the

guidance on the process for establishing refusal or resistance to an assisted death will be confirmed by the Committee following consultation (in accordance with all other guidance and training).' [179]

Recommendation 12: Ensure adequate training is given to assess what constitutes a refusal of administration and consider if any tools currently used with non-verbal people are appropriate.

4. Ensuring that the individual makes an informed decision

The draft law stipulates that an individual's decision to have an assisted death must be an informed decision and sets out the information that must be provided to the individual prior to confirming their eligibility for assisted dying. This includes the physical condition that is expected to cause their death; the expected course of the condition; options for care and treatment including options that are end-of-life or otherwise palliative; and the likely outcomes. [180]

The Minister for Health and Social Services has emphasised that the Assisted Dying law places a very clear duty on assessing doctors to ensure that the individual's request for

an assisted dying is informed'. [181] But we would question whether a person can be fully informed of end-of-life and palliative care options if they have not spoken to an end-of- life expert, whether this be a nurse or doctor. The assisted dying practitioner is unlikely to be able to have the most informed discussion on these options. We note the Jersey Care Commission's suggestion that:

the Draft Law may also be further strengthened by explicitly requiring the involvement of palliative care specialists in the assessment process and by mandating that all palliative care options are fully explored prior to proceeding. In other jurisdictions, the inclusion of clear referral points to palliative care services helps ensure these pathways remain integral, thereby supporting informed choice and enhancing patient well-being.'[182]

In most jurisdictions, it is mandated that palliative care options are explored, but this is done by the assisted dying practitioner who provides all care options. Hence, the onus

is on the assessing practitioner as to whether they feel sufficiently trained to explore end-of-life options. A recent paper [183] from Belgium found that although a palliative care assessment was not enshrined in their law, when assessments were being made by

them, they predominantly included the palliative care team in the assessments. However, the lack of clarity in the law led to:

1. Assessing doctors being accused of trying to delay an assisted death if they did refer to palliative care
2. Makes assessing doctors uncomfortable to ask for palliative care assessment due to reaction

The authors say that The results provide an opportunity for policymakers to take action to better support providers to manage these challenges'.[184]

Question: Given the support of the Jersey Care Commission for carrying out a palliative care assessment as part of the assisted dying assessment, are they willing to provide this service? It would act as a stronger safeguard to ensure that the individual's decision is fully informed.

The Panel will need to consider whether, if it favours the inclusion of this additional safeguard, the draft law should mandate that palliative care options are discussed by end-of-life/palliative care specialists during the assessment process (reflecting the Jersey Care Commission's recommendation above). Alternatively, if the Panel wishes to ensure that the individual is given the opportunity to be informed about all palliative care options by an end-of-life/palliative care specialist (doctor or nurse), but to allow the individual to decide whether to avail themselves of this opportunity, the draft law could mandate that they be offered this option. It may be that the latter would be the preferred approach. The Minister for Health and Social Services has stated that:

the law does not mandate that the person must have a palliative care assessment on the basis that:

• access to palliative care should be a patient-held choice, something that is offered but not mandated

• mandatory palliative care assessments may not be appropriate in all circumstances – for example where a person has a life expectancy of less than 14 days and has already received / are receiving significant end-of-life care and palliative support from palliative care specialists.'[185]

We would argue that a legal requirement that the patient be offered the opportunity to be informed about all palliative care options by an end-of-life/palliative care specialist would:

• still ensure a patient-held choice, as the patient can accept or decline this offer;

• avoid the repercussions of the lack of clarity in a legal position that does not clarify that a palliative care discussion be carried out with a specialist, such as in Belgium; and

• would better ensure that this information is provided by a specialist expert.

However, we propose both options of a mandated discussion or an offer for a discussion with an end-of-life/palliative care specialist, for the Panel's consideration.

Recommendation 13.i: That, in order to be fully informed of end-of-life and palliative care options, there be an additional requirement within the draft law that the person must have spoken to an end-of-life/palliative specialist (nurse or

doctor) prior to the assessing doctor confirming the individual's eligibility for assisted dying;

OR

Recommendation 13.ii: that, in order to be fully informed of end-of-life and palliative care options, there be an additional requirement within the draft law that the person be offered the option to explore all palliative care options with an end- of-life/palliative care specialist (doctor or nurse) prior to the assessing doctor confirming the individual's eligibility for assisted dying.  

6. Providing information, continuing ongoing support, care and treatment for the individual whilst requesting an assisted death and on the assisted dying process, and supporting their family members and loved ones

1. Providing information

Information and support on assisted dying for all Islanders will be provided by the Assisted Dying Service, including online and printed information materials. [186] Additionally, the Committee must arrange for the Assisted Dying Service or another supplier to develop general information about the assisted dying process.[187] Schedule 1 of the draft law sets out what general information should be provided, as follows:

GENERAL INFORMATION ABOUT ASSISTED DYING PROCESS

The general information about the assisted dying process must include information about –

1. the criteria for assisted dying;
2. each step of the assisted dying process;
3. the Service, including its contact details;
4. the right to appeal certain decisions under this Law;
5. how an individual, their connected person, an assisted dying practitioner, a certifying doctor or a care navigator can obtain support (such as counselling) relating to assisted dying;
6. how someone may complain about the services that they or others have

received; and

7. matters that an individual may want to consider before their assisted death

(such as life insurance or other personal administrative or financial matters).' [188]

As part of the duty to ensure that an individual's decision, or request, to

have assisted death is informed, the assessing doctor must ensure that the individual has been provided [with] the general information, and to be satisfied that the individual has understood the general information.' [189]

On the issue of whether a health care professional can initiate an assisted dying discussion with a person, the draft law permits health practitioners to raise the subject of assisted dying, with the objective of helping support equality of access. [190] This reflects the position favoured by the BMA that there should be no prohibition on raising the issue of assisted dying with patients'.[191] Notably, in the State of Victoria, Australia, the so called 'gag clause' under its assisted dying law has proven to be problematic and has recently been removed due, in large part, to doctors' advocacy. [192]

It is also explained in the report accompanying the draft law that the function of "initial discussions" are covered by assisted dying service model where patients are referred into Service or self-refer for a preliminary discussion prior to making first request.'[193] It thus seems to be anticipated that any initial discussions will take place through the Service, with other health professionals (merely) providing the contact details for the Service. The Appropriate Conversations guidance that the Committee will be required to develop will offer further assistance for health care professionals. If the expectation is that any health professional who is not part of the Assisted Dying Service will refrain from any initial discussions about assisted dying and simply provide the contact details for the Service, this will need to be made explicitly clear in the guidance.

Provided that a health care professional only gives information:

(i) about the availability of assisted dying and related services;

2. about where more information on assisted dying can be found;
3. about their role in assisted dying; or
4. that supports awareness and understanding of assisted dying' [194]

Then as long as they do not do so with the intention of persuading or encouraging anyone to have an assisted death', [195] they act within the boundaries of the draft law and do not commit any offence of promoting or advertising assisted dying under Article 50.

The Citizen's Advice Bureau (CAB) submitted a response to a request to comment on whether there has been sufficient public awareness about the draft assisted dying law. They responded that while a number of methods have been used to publicise the issue, some people may be unaware and therefore need additional methods:

For some members of our community, it is possible that they may be "in the dark" on this issue particularly, the infirm that may have sight or other sensory disabilities, those residing outside of a domestic setting who may not venture outside regularly or do not access media or the internet.

In the event that the draft law is passed by the States Assembly, aside from normal channels of public communication such as media, perhaps a leaflet could be created as a mail shot explaining that the Assisted Dying Law is coming into force and making it clear that it is intended purely for public awareness. This could cover where information may be found on a specific website or alternatively a contact number to gain further information.

Perhaps posters could be created detailing basic information such as eligibility

which can be distributed to organisations such as our own for public display.'

2. Providing support

The intense emotional experience of their loved one's assisted death and the challenge of the process involved has been described in the academic literature. [196]

One of the obligations of the Assisted Dying Assurance and Delivery Committee will be to arrange the development and maintenance of the Family and Carers Guidance that will provide accessible, easy to understand information on important matters such as accessing support services and how to support a family member who is requesting assisted dying and how to raise a complaint. [197]

In some jurisdictions such as New Zealand, support throughout the assisted dying process and bereavement care afterwards is provided by existing bereavement and mental health services. The Ministry of Health noted that some submissions to its 2024 review of the operation of the assisted dying legislation asked that funded specialist holistic care and bereavement support be provided to families and whnau as part of

the Assisted Dying Service, or through creating Assisted Dying Navigator' roles. However, the Ministry concluded that additional support functions would not need to be separate to those provided in the rest of the health system to avoid duplication of existing support and to avoid distancing assisted dying from deaths. [198]

The approach under Jersey's draft law will involve a distinct care navigator support role throughout the assisted dying process, as we will discuss further in the following sub - section. This is also the approach adopted in Australian states and, depending on the scope of this role in the particular state, these care navigators may provide support throughout the process and bereavement and grief support to loved ones afterwards. Alternatively, as in Western Australia, they can assist patients, family and carers to access voluntary assisted dying grief and bereavement support services and resources, including community support groups for people with lived experience of voluntary assisted dying'. [199]

The key message from the international experience is that whether support for individuals requesting an assisted death and their families is provided as a part of the assisted dying service or through existing support services in the health system, these services play a vital role in improving access to and understanding of assisted dying'.[200] However, such support services have encountered capacity challenges, and thus, there is a need for sustained investment to help ensure equitable access to this support. [201]

In acting to achieve the safeguarding objective to protect and support all islanders, the report accompanying the draft law states that Family members and friends may access wellbeing and bereavement support',[202] and the draft law requires counselling and bereavement support to be made available to family members/friends via the Jersey Assisted Dying Service'.[203] Training requirements for all assisted dying practitioners will include bereavement training – support for self, colleagues, family and friends of individual'. [204] The costs of this support have been factored into the recurring costs for the Service. [205]

The relevant Article of the draft law stipulates that the Assisted Dying Assurance and Delivery Committee must arrange for the Service or another supplier to develop and provide support (such as counselling) for individuals and their connected people'.[206]

This therefore suggests that bereavement support will either be provided by (within) the Assisted Dying Service, or that the Service will refer families and friends to a supplier of bereavement services. However, there is evidently a capacity concern if the Committee were to decide that family bereavement support for assisted dying be provided by existing service providers rather than from within the Assisted Dying Service. In the Impact Report for the Palliative and End of life Care Strategy for Adults in Jersey 2023 - 2026, it is stated that:

The Emotional and Bereavement Service at Jersey Hospice is a very busy service that supported over 400 islanders in 2024 Referral rates for adults have continued to increase year on year. During 2022 - 2023 there was an increase in referrals of over 4% and in the following year, this jumped to 12% increase. As a result, the average caseload has increased by 38% over two years.'[207]

We would also suggest that support for family and friends should be extended to the witness of the signing of the second request form,[208] as this could be a challenging role.

Recommendation 14: Check the capacity of current bereavement services and whether those working for these services would be willing to take on this role for assisted dying, unless the costed-for bereavement services are to be provided within the Assisted Dying Service or through an alternative provider.

3. The care navigator role under the draft law

The draft law includes the role of a care navigator, [209] and this role and its responsibilities are defined in the accompanying report as being:

A non-clinical staff member who will support the individual requesting an assisted death and support the Coordinating Doctor to coordinate the process. The initial point of contact for information and enquiries into the Assisted Dying Service. The Care Navigator must complete the mandatory assisted dying training, but they do not need to be registered with the Assisted Dying Service because they are not clinical staff. [210]

Only Care Navigators employed by the Assisted Dying Service will be able to take on this role and, thus, it is not envisaged that a register of Care Navigators is required.[211] On the basis of the estimated total number of deaths through assisted dying, the HCJ Director

of Workforce's preliminary projections of the numbers of staff required in each assisted dying role once the Service is fully implemented, the number for the Care Navigator role is 1.0 FTE. [212] Ensuring sufficient capacity is a key concern given the international experience regarding equity of access and sustainability. It is important to ensure that those who take on this role are not over-burdened if capacity cannot meet demand.

Whilst we appreciate that this is more likely to be an issue to be decided during the implementation stage if the draft law is passed, given that this would be a new role for Jersey, the question of what qualifications or experience a person would need to have to undertake this role will need to be addressed.To assist on this, looking to the essential requirements for this role in other jurisdictions where it is already offered would be advisable.[213]

The report accompanying the draft law states that prior to the face-to-face meeting with

a Coordinating Doctor to make their first request, the individual may, over a period time, have had several discussions with the Care Navigator about assisted dying process

which may have included being referred by the Care Navigator to other relevant support services.'[214] This indicates that it is envisaged that the individual's professional relationship with a Care Navigator could have begun earlier and, potentially, some time before their first assisted dying request. It is also clear that individuals can self-refer themselves to the Assisted Dying Service. [215] However, it is not clear from the draft law or the accompanying report how a person would go about self-referring themselves and thereby having access to a care navigator. Will patients know that their GP can provide them with the contact details for the Service, for example? [216]

The training for care navigators will include providing support to:

assessing doctors and extended team during assessment phase; administering practitioner during care planning and delivery phase; individuals and their family members; handling referrals and enquiries into the Assisted Dying Service record management.'[217]

Related to this, one matter that requires further consideration and probing is whether

the Care Navigator's support continues in the case of an individual assessed to be ineligible for an assisted death. The need for support for these individuals, who could be deemed a vulnerable group, is demonstrated by international experience. The New Zealand Ministry of Health's review of the assisted dying law highlighted concerns regarding support for this group, who are at risk of falling through a support gap. In New Zealand, there are:

currently no obligations on practitioners in the legislation to provide or facilitate support to a person who has been found ineligible for assisted dying, or for the friends, family, or whnau of a person accessing assisted dying.'[218]

New Zealand's Ministry of Health did not recommend that the legislation be amended to impose stronger requirements to facilitate support after a person is assessed as ineligible for assisted dying. However, it did consider it appropriate that there be strengthened operational guidance, to enable flexibility and responsiveness to a person's circumstances and needs' and that Training could also be strengthened to encourage practitioners to refer a person back to their regular health provider or ensure that they are aware of resources available in their area for support.'[219]

The Addendum to the draft law provides an indication of the initial support that it is envisaged will be offered in Jersey to anyone deemed ineligible. The anticipated content of the guidance on having appropriate conversations with patients includes support for a patient who has had their assisted dying request declined, to be provided by health and care professionals when they are having conversations with a patient who is going through the assisted dying process, whilst providing ongoing care and treatment to that patient'. [220] The Addendum also states that the target audience for this guidance would include other professionals whose clients may request assisted dying (e.g. staff of cancer support charities)'.[221] The additional training modules that assessing doctors will receive will include a module on supporting those whose assisted dying wish is declined.[222] Moreover, there will be signposting and support for those who are assessed as not eligible for assisted dying, including onwards referral to specific services if any safeguarding concerns or additional social care needs are identified.'[223]

Whilst it is positive that a patient whose request for an assisted death is declined could access support and receive signposting to specific services from a number of different professionals involved in their care and assessment, it is important to ensure that there is no risk of a gap. This might occur if each of the professionals who could potentially provide this support – the assessing doctor, the health/care professional or professional from a cancer support charity, e.g., who has had the initial discussion about assisted dying – is of the opinion that someone else will be offering this support/signposting.  

Recommendation 15: The draft law should require that the Assisted Dying Assurance and Delivery Committee be under a statutory duty to give due consideration to models of good practice on the appropriate experience and qualifications for the care navigator role in jurisdictions where assisted dying is permitted.

Recommendation 16: There will need to be clear guidance available to the public on what a person would need to do in order to self-refer and have access to a care navigator.

Recommendation 17: Consider whether the support for those who are assessed as not eligible for assisted dying should be provided by care navigators, to ensure that there are no gaps in the provision of this support.

7. Sharing of fitness to practice information with the GMC and other professional regulators

On the Articles of the draft law that enable the sharing of fitness to practise information with the GMC and other professional regulators, we note that the GMC recommends a minor revision to the wording of Articles 70(2) and 85(2) (now Articles 72(2) and 87(2) respectively). [224] This should avoid a narrower judicial interpretation of these provisions that would limit the disclosure of information to that within the category set out in Article 41(1), [225] and not to the categories of information covered in Articles 72(1) and 87(1). [226] Whilst this may be a small risk, as the GMC recognises, the suggested amendment would seem to us to be an important way of removing the risk to enable the GMC to act effectively and quickly to investigate concerns, and thereby protect the public.

8. Potential public protection gap: Professional bodies' investigation of health care professionals working for the Assisted Dying Service: suspensions and removal from professional register

There are further important recommendations from the GMC that we support in order to provide greater certainty that professional bodies can investigate health professionals working for the Assisted Dying Service when it is appropriate to do so. None of these recommendations would seem problematic or controversial in our view, and so we simply include them here:

44 To avoid any public protection gaps, we also suggest that you explicitly mention interim suspensions in Article [85]. As explained above, we can refer a case to an interim orders tribunal (IOT) to consider imposing an interim order while we investigate a complaint against a doctor. We do this when we believe the doctor's practice should be restricted to protect members of the public, or if it's in the doctor's interest. The IOT may suspend or impose conditions on a doctor's registration for up to 18 months. Article [85](1) should reference suspension, on an interim or substantive basis.

45 In discussing the draft legislation, we also suggested that you may want to consider including reference to conditions' alongside suspension in Article [85]. This is because conditions imposed by us to restrict a doctor's practice may lead the Committee to consider that it would be appropriate to suspend or remove the doctor from the Assisted Dying register. We suggested that it may be useful to use the term restrictive action' in the legislation rather than outcomes' to help with this issue.

46 The use of the term cancellation' in Article [85] is not consistent with the terminology used by health and social care regulators in the United Kingdom. This means that as currently drafted, there is a risk that you will not capture all types of removal from our register.'[227]

CRIMINAL LAW OFFENCES

The existing criminal law in Jersey is uncertain in respect of assisting the suicide of another. This was explored for the Citizen's Jury in 2021. Mullock and Ost's work for the Citizen's Jury, after consultation with the Law Officers, outlined the current Jersey law as follows:

Suicide and attempted suicide

1. homicide de soy-même' was a crime under Norman customary law (felo de se in English common law)
2. This had implications for the property of the deceased, as a distinction was drawn between someone who was mentally distressed at the time of the act (whose property was not forfeited) and someone who acted deliberately and calmly (whose property was forfeited)
3. In the Criminal Commissioner's Report of 1847, the law had not changed but what was happening in practice had.
4. Mid-19th century inquest juries automatically assumed that the person

concerned was in such a state of distress that no criminality attached to the act

of suicide.

a.  That is to say technically homicide de soy-même' remained an offence, but was not ever criminalised

5. Therefore the offence of attempted suicide remained (because suicide was technically still an offence)
6. However there have been no prosecutions of attempted suicide since the 1900s
7. Customary law can be changed by usage, and a prosecution for attempted suicide would not happen these days
8. There is evidence that the Courts of Jersey no longer treat suicide as a criminal act:
   1. A case heard by the Royal Court in 1995 (Forbes) allowed for a suicide note to be used in probate – therefore acknowledging that the deceased was in a rational state of mind when committing the act, yet the Court did not apply the original Normal law (see point 2 above).
9. This suggests that suicide is no longer regarded as a criminal act by the Court
10. If suicide no longer carries any criminal liability, then neither does an attempt to commit suicide

Aiding and abetting suicide

11. Article 6(b) of the Homicide (Jersey) Law 1986 notes "the offence of aiding, abetting, counselling or procuring a person's suicide".
12. However, if as above (point 11) an attempt to do something that is now lawful cannot be a criminal offence, then the aiding, abetting, counselling or procuring' something which is now lawful also cannot be a criminal offence.
13. Jersey has not abolished the crime of suicide by statue, but the law has fallen into desuetude' [disuse], which in effect appears to decriminalise aiding and abetting' suicide.
14. However, there may be cases where the facts amount to the offence of aiding or abetting suicide to be charged as attempted murder.

1. Attempted murder and aiding, abetting, counselling and procuring murder are all recognised under Jersey law.

A clear advantage, therefore, will be that the assisted dying law clarifies this uncertainty.

Some of the other offences under the draft law that we will now proceed to consider, including the offences on coercion, dishonesty, pressure, falsification of documents)

are similar to aspects of the Terminally Ill Adults Bill (England and Wales), [228] but Jersey has additional offences that we will also discuss below; coercing a person to withdraw a request, and purporting to act as an assisted dying practitioner.

1. Coercion offence

As has been noted in the academic literature, through creating a specific coercion offence, more protection could be granted to patients, as it reinforces a strong commitment to ensuring that the choice of assisted suicide is genuinely autonomous and voluntary.' [229]

The draft law sets out an offence to coerce or dishonestly induce a person's decision regarding assisted dying. [230] This occurs when someone coerces or dishonestly induces another person to:

(a) request assisted dying;

2. decide to end their life by assisted dying or request assisted dying, including to request to proceed to the next step of the assisted dying process; or
3. withdraw their request for assisted dying.'

The maximum sentence that can be imposed for this offence would be imprisonment for 14 years. This would seem to be an appropriate maximum penalty, mirroring as it does that which would be imposed under the new assisted suicide offence to be added to the Homicide (Jersey) Law 1986 via the draft law. [231]

It is noteworthy that one way in which this offence can occur is where someone is coerced or dishonestly induced to withdraw their request under the draft law. There is some evidence related to the pressure that relatives might exact to try and discourage a person, or the relevant administering practitioner, from performing the assisted death. Some of the Dutch GPs interviewed in a study by de Boer, Depla, den Breejen and others reported that they had encountered counterpressure from relatives strongly opposed to assisted dying. [232] This reluctance to go against the relatives' wishes could be felt even more strongly by the patient. [233]

Looking to comparable offences under assisted dying laws elsewhere, under Victoria's VAD Act 2017, it is an offence to induce another person to make a request for assisted dying or to self-administer the assisted dying substance by dishonesty or undue influence, with a maximum penalty of 5 years imprisonment. [234] Western Australia's Voluntary Assisted Dying Act 2019 additionally includes direct reference to coercion as one of the means of inducing a person to request or access voluntary assisted dying', besides dishonesty or undue influence. The penalty imposed is longer: 7 years imprisonment, [235] but notably, it is life imprisonment for the offence as related to inducement to self-administer the assisted dying substance. [236]

Under the law in Oregon, it is a Class A Felony (the most serious category of offence in the US) if any person:

without authorization of the patient willfully alters or forges a request for medication or conceals or destroys a rescission of that request with the intent or effect of

causing the patient's death'

coerces or exerts undue influence on a patient to request medication for the

purpose of ending the patient's life, or to destroy a rescission of such a request, [237]

The maximum sentence on conviction is 20 years, with a maximum fine of $375,000 on conviction.

2. Other criminal offences  

In addition to the coercion' offences, [248] [238] sets out that the draft law provides that it will be an offence:

• to unlawfully administer, or assist in the administration or self- administration of the approved drugs unless in accordance with the law (Life, akin to homicide)

• to give a false or misleading statement or forge a document, which would include the individual, their friends or family giving false information to an assisted dying practitioner or assisted dying practitioner giving false information, including as part of the assisted dying registration process (5 yrs)

• not to tell the Service about significant registration matters i.e., an assisted dying practitioner commits an offence if they do not tell the Service, for example, if their professional registration as a doctor (whether in Jersey or the UK) has been cancelled, suspended, or had conditions imposed

• to disclose information that they are prohibited from disclosing, for example, information that allows for identification of an individual, the assisted dying practitioners involved in an individual's assisted dying process, or the approved drugs (see paragraphs 225 - 231).'

Other offences deal with false representation as an assisted dying practitioner,

certifying doctor, care navigator, or part of the Assisted Dying Service. A final offence is created under Article 50 regarding activity to:

promote or advertise assisted dying with the intention of persuading or encouraging anyone to have an assisted death'. But this does not prevent providing information for legitimate purposes, e.g. the government providing information about the service or a GP telling people that they are an assisted dying practitioner.'

The offences under Articles 47 (to purport to act as an assisted dying practitioner, certifying doctor or care navigator) and 48 (to purport to be an assisted dying practitioner, certifying doctor or care navigator) seem, on the face of it, to be very similar. The offences are designed to safeguard against people being misled or scammed by third parties seeking to generate income (for example by offering a paid for assisted dying pre-assessment process) or for other such purposes.' [239]

There is a question as to whether there is a clear, meaningful difference between intentionally purporting to act as..' and purporting to be', from reading the offences, and this could then raise the question of why there are a significantly different sentences (14 years for the Article 47 offence versus 7 years for the offence in Article 48). The different sentences certainly indicate that the Article 47 offence is the more serious offence. Looking to the report accompanying the draft law, it would seem that the Article 47 offence is the more serious offence because it applies where someone acts in the roles when they are not registered to do so. The Article 48 offence involves a false pretence [240] - someone falsely pretends to hold one of these roles or allows another person to state they hold that role. However, this distinction is not necessarily clear from the wording of the relevant clauses themselves. Also note that the issue of imprisonment potentially raises human rights law in respect of Article 5 ECHR (Deprivation of liberty), see the later section on human rights. Under Article 50 the offence of promoting or advertising assisted dying raises the question of where a line should be drawn between the important and legitimate goal of providing information on the one hand, and promoting or advertising assisted dying in a way that invites criminal liability. However, we are satisfied that the law sets out the position clearly in Article 78(3). Note we have also considered this in section 5, Providing Information. We briefly note that the other offences under Articles 51 to 53 appear to be clear and therefore raise no concerns.

Recommendation 18: That the distinction between the offences under Articles 47 and 48 be clarified.

APPEALS

1. On the health criteria decision

The change: P.18/2024 set out that the grounds for appeal would not include matters relating to health criteria (i.e., the individual's diagnosis and prognosis or their beliefs related to their suffering / anticipated suffering). In discussion with law officers this position has been amended. The draft law now provides that the individual/person with a special interest may appeal a decision on the health criteria decision but only if that decision is irrational (i.e. a decision that is flawed or so unreasonable that it could not be sensibly reached) or not made in accordance with the law.' [241]

The addition of the matters relating to the health criteria accords with the approach (based on judicial review principles) that appeal against a refusal to allow an assisted death can only be made on the grounds that the decision was irrational, unreasonable

or not in accordance with the law. [242] This seems to raise no problematic legal or ethical issues, and the approach in P.18/2024 of excluding health matters would be potentially problematic because the assessment of health (terminal illness, prognostication) is crucial to accessing assisted dying. Therefore, this is a positive and entirely reasonable amendment to the earlier approach.

2. Appeal by a person with a special interest against a positive decision

Article 42 of the draft law provides that a person with a 'special interest' may appeal against a positive decision to provide assisted dying. This may be done in respect of the health criteria when there are grounds to challenge the decision on the basis of it being irrational, unreasonable or not made in accordance with the law. [243] This provision is extremely unusual; our research indicates that only one other jurisdiction (Queensland, Australia) allows any form of third party review or appeal.

The report accompanying the draft law explains key information about who may be regarded as having a 'special interest':

It is for the Court to be satisfied whether a person has a special interest. This may be, for example, a family member or a professional involved in the individual's assisted dying process. It does not include an unconnected third party (such as a representative of a lobby group) who is appealing a decision of the Coordinating Doctor on the basis that they do not support assisted dying.'[244]

The guidance states that an appeal is permitted when: the application is approved at step 5 based on the issue of whether the individual meets one or more of the criteria for assisted dying', or, whether a doctor or practitioner reasonably believes relevant

matters under Article 17(2) for the individual's request to proceed to the next step', or whether the co-ordinating doctor reasonably believes the matters under Article 17(2)(a) for the individual's request to proceed from step 5 to 6.'

Looking at international comparators, the overwhelming majority of other jurisdictions permitting assisted dying do not allow appeals from third parties against any decision. One exception is Queensland in Australia. The Queensland Civil and Administrative Tribunal (QCAT) allows either the person seeking to die, their agent, or another person who has sufficient interest to request a review of a decision. This is provided by part 7 of the state's Voluntary Assisted Dying Act 2021. With respect to who qualifies as a person with sufficient interest, this is explained as any other person who has a sufficient and genuine interest' in the rights and interests of the person seeking voluntary assisted

dying (VAD), for example another member of your healthcare team, a spouse or other close family member, or carer.' [245] We have not found any reported examples of cases where a relative or other third party has requested a review of a positive decision to provide VAD, nor any problems arising from the review procedure. [246]

The Terminally Ill Adults (End of Life) bill does not (currently) include any right of appeal against a positive decision by an interested person. The only right to challenge/appeal within the TIA Bill is in respect of a negative decision, in which case the person seeking an assisted death may request the Assisted Dying Commissioner to review the panel decision. [247]

One concern that might be raised is whether a third party right of appeal breaches legal and ethical expectations, either of patient confidentiality and/or the right to determine one's own medical treatment and end-of life pathway. Both issues may raise possible violations with Article 8 of the ECHR. While the discussion of human rights law in the draft law report [248] correctly sets out the position in respect of the wide margin of appreciation regarding the broad human rights issues raised by legalising assisted dying under the model proposed, this does not cover the prospective of a third party right of appeal and the potential for ECHR violation (see the Human Rights section below).

Recommendation 19: Consider whether a third party right of appeal against a positive decision (Article 42(3)) should be included, given the possible Article 8 ECHR violation in respect of an interference with the autonomy of a person who has been assessed as having mental capacity.

NO FEES FOR ASSISTED DYING SERVICE, POSSIBLE FEES IN THE FUTURE AND EQUITY OF ACCESS

Change from P.18/24 para. 284

In accordance with P.18/2024 the draft law provides that there must be no fee for any part of the service, however, article 94 states that the Assembly may in the future, by regulation, introduce fees for a range of reasons that are consistent with their approach to health service fees.

Since Jersey residents currently must pay for GP services and outpatient treatment, although these may be subsidised, this approach accords with the general principles of accessing healthcare in Jersey, however, there are ethical issues regarding equity of access that should be considered.[249]

MEDICAL ASPECTS

1. Training

It is stated in the report accompanying the draft law that there will be other training which may be completed by anyone who provides health and care services in Jersey (if they wish to complete the training), and which must include training on appropriate conversations (Article 66)'. [250]

The focus of the training recommendations is on understanding the service and how to implement assisted dying, which is similar to that which is provided in other countries. However, training might also cover how teams continue to work together, whether or not they are involved directly in the assisted death. Other staff may want guidance on how to maintain a therapeutic relationship with the patient, even though they do not want to be part of the assisted death. As assisted dying is such an emotive subject, and if the plan is to integrate it into general health care, there will be times when clinicians disagree or feel excluded from end-of-life choices, whether intentionally or not. This could result in difficulties in how teams communicate and work together. There can also be issues in the wider team about how decisions are made and how different voices can be heard. Maintaining cohesion in the health care team will be vital. [251]

Training requirements for health care professionals are being developed by the European Association of Palliative Care's (EPAC) Taskforce on the role of palliative care professionals caring for patients and families seeking and accessing assisted dying.[252] The recommendations from this could help address these broader training requirements.

The draft law does not set out who specifically should be consulted when the training and guidance is being developed, stating instead that they should be those persons that the Committee or the Minister requires to be consulted and anyone else that the

Service or other supplier thinks it is appropriate to consult. [253] The only stipulation is that, in deciding on the persons who should be consulted, each person's functions and knowledge of health professionals' practice must be taken into account. [254] This offers flexibility to the Committee, Minister and Service to consult the most appropriate stakeholders and experts. The Addendum notes that the Committee would be required to consult with persons and organisations with relevant expertise, including for example the professional regulatory bodies.' [255] However, the Panel may wish to consider whether there would be additional reassurance that the training reflects the most up-to-date research findings, standards and practice on identifying coercion and pressure, and is appropriately directed towards the professionals who will undergo it, if the draft law were to stipulate that key professional regulatory bodies should be consulted on this training. Whilst we would not expect these bodies to be listed in the draft law, we note that these regulators could include the Jersey Care Commission, General Medical Council (GMC); Nursing and Midwifery

Council (NMC); Health and Care Professions Council (HCPC); General Pharmaceutical Council (GPhC) [256] and Social Work England (SWE). [257]

According to the report accompanying the draft law, it would be necessary for health professionals who work for the Assisted Dying Service to have their training renewed every three years. [258] This will also be vital to ensure that the assisted dying practitioners' training reflects the most up-to-date research findings, standards and practice on identifying coercion and pressure, and to help prevent this becoming more of a tick box exercise. However, this renewal requirement is not actually set out within the provisions of the draft law itself, which states that The Committee must set the intervals at which the continuing training must be completed for each role', and this reflects what is also stated in the Addendum. [259] We can see the advantage noted above in relation to not specifying the exact content of the training in the draft law itself, if the timing of intervals between training is left to the Committee.

Recommendation 20: Broaden training to include issues for the wider health care team (not just the extended assisted dying team) on how to handle their feelings, maintain team cohesion etc.

Recommendation 21: That the draft law stipulate that key professional regulatory bodies should be consulted on the training.

Recommendation 22: That it be clarified whether the training should be renewed every three years as stated in the report accompanying the draft law. If so, then this should actually be specified in the draft law. Alternatively, it may be considered that this matter is more appropriately dealt with by the Assisted Dying Assurance and Delivery Committee, so that the maximum period of time that can pass before training must be renewed can be amended more easily to keep in line with professional standards and benchmarking.

Whichever is the preferred approach, there is an inconsistency that requires correction between statements that the intervals being left to the Committee to decide within the draft law and the Addendum, and the stipulated three years provided in the report accompanying the draft law.

2. Matters relating to assessing capacity

The draft law provides that, at this first step in the process, the Coordinating Doctor must explain to the individual that they can choose whether to permit the Assisted Dying Service to share information about the individual with others (for example, with other health care professionals, friends or family members). Whilst the individual may choose not to permit information sharing, this may impact on the assessing doctors' or Administering Practitioner's ability to determine if the individual meets the eligibility criteria. [260]

Besides their meetings with and assessment of the person, the evidence which could help form the doctor's view that the person lacks capacity can come from the relevant opinions of others, [261] with such others' being connected people's personal opinions that the doctor or practitioner thinks will help them to decide, or form their belief, about the matter'. [262] Thus, doctors may wish to approach the person's family when carrying out the capacity assessment.

Additional training modules for assessing doctors will include a module on the role of family friends in the assessment process, [263] however, it is unclear whether this will also cover the situation where the doctors are unable to speak to family and/or friends.

At the end of the Second Request stage (Step 4), the coordinating doctor must reasonably believe' that the individual has capacity to make an assisted dying

request. 271 This is also required of the Administering Practitioner at the end of Step 6 (care planning) 272 in order to proceed to Step 7 (the final review and carrying out of

an assisted death) unless the individual has waived the requirement for future

capacity. 273 The requirement for a reasonable belief' is consistent with the Capacity and Self-Determination (Jersey) Law 2016, 274 and inclusion of the word reasonable' in terms of doctors' professional judgements is supported by the BMA. 275

Recommendation 23: Training for assessing doctors should cover assessing capacity when unable to speak to friends and family.  

Recommendation 24: Training for assessing doctors should cover ensuring that the patient is made aware that approaching some family members or friends can be helpful to fully assess capacity.

3. Terminal illness

Here, we consider whether the draft law in relation to the definition of terminal illness (health criteria' for eligibility) prevents expansion or unintended broadening of the eligibility criteria. We have included this here within the Medical Aspects' section, but we note this is also a legal question of interpretation that relates to questions of safeguarding.

Under Article 2(2), Criteria for Assisted Death:

An individual is eligible for assisted dying if they meet the criteria under this Article ("criteria for assisted dying"). (2) The health criteria are that, when the individual is assessed – (a) they have a physical condition that is expected to cause their death within the required period of –

1. 6 months; or
2. 12 months if the condition is neurodegenerative;'

The Jersey draft law does not demand that the health criteria are not treatable, only that such treatment is too burdensome from a subjective perspective:

if treatment could extend their life beyond the required period, or make their suffering from the condition bearable, they believe that they would not be able to bear the suffering that the treatment is expected to cause them.' [264]

This raises the question of when it might be agreed by the doctors assessing the patient that it is lawful and ethical to proceed to facilitating the assisted death when a

treatment is available that could extend life beyond the required period of six months, or twelve months for neurological conditions. For example, in case study Person 5' (Sonia), [265] there is an initial refusal to undergo surgery to remove a melanoma, which would lead to a good prognosis. This case study explores the issue of coercion from Sonia's partner, rather than the question of whether such a refusal, if maintained, would or should make Sonia eligible under the health criteria. The other aspect of the health criteria - that there must also be suffering or anticipated suffering that the patient

deems unbearable - means that doctors will take a holistic assessment; first, of the condition expected to cause death, second, the suffering that the condition is causing, or may cause, and finally, the suffering that any treatment might cause. This might be

regarded as appropriate; however, if the patient has a prognosis similar to that described for Sonia, it might lead to allowing assisted dying for a patient who may fully recover from the cancer, or at least survive for several years if they accepted treatment. This may have been intended by the States Assembly, however, since they voted to reject Route 2 (eligibility based on unbearable suffering in the absence of a terminal illness) in May 2024, it might be the case that the States Assembly would prefer to have a more restrictive definition under the health criteria.

In some jurisdictions the question of what might constitute an illness or condition expected to be fatal (terminal) within a set period of time has generated significant debate. Concern that people who are not terminally ill in a narrow clinical sense, e.g. those with a terminal cancer diagnosis, but who could survive with treatment (e.g., people with advanced anorexia nervosa), will be regarded as eligible under legal definitions has been raised. For example, in Westminster, the definition within the Terminally Ill Adults Bill (hereafter TIA Bill) has been debated . The TIA Bill (as of November 2025) defines terminal illness as an inevitably progressive illness or disease which cannot be reversed by treatment'. [266]

Definitions from other relevant jurisdictions requiring a terminal condition include: Oregon, Death with Dignity Act, chapter 127:

(12) "Terminal disease" means an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months.'

New Zealand, End of Life Choice Act 2019:

Clause 5(1); (c)suffers from a terminal illness that is likely to end the person's life within 6 months; and (d) is in an advanced state of irreversible decline in physical capability'

Victoria, Australia, Voluntary Assisted Dying Act 2017:

Clause 9(1) (d) the person must be diagnosed with a disease, illness or medical condition that (i) is incurable; and (ii) is advanced, progressive and will cause death; and (iii) is expected to cause death within weeks or months, not exceeding 6 months; and.. (suffering clause)'

A further limitation outlined in some law (e.g. TIA Bill, New Zealand, Victoria) is that a person will not be eligible for assisted dying by reason only of a mental illness/disorder. The question of what conditions might be included within the understanding of terminal illness' became a point of concern in relation to anorexia in the House of Commons Committee stage of the TIA Bill. An argument that a vague definition of terminal illness that might potentially allow people to become eligible as a result of refusing treatment, was linked to a possible anorexia loophole'. [267]

The TIA Bill strives to avoid that risk by demanding that the terminal illness is an inevitably progressive illness or disease which cannot be reversed by treatment'. Because anorexia nervosa is not inevitably progressive, and it can be reversed with treatment, it seems likely that the restrictive language will succeed in limiting access (in England and Wales) to those with terminal physical conditions that are inevitably going to cause death, even if treated.

One of the Jersey case studies [268] deals with this issue, however, because Sadie' also has a terminal heart condition, she would probably be eligible under the health criteria' due to the heart condition, irrespective of the anorexia - though not necessarily with respect to other eligibility criteria, especially capacity. Nevertheless, this case study illustrates that a person with a serious mental health condition such as anorexia may develop serious physical conditions, perhaps as a result of the anorexia. There may be clinical uncertainty over whether such a physical condition is expected to cause death, and, if so, whether it is appropriate to regard this as a physical condition for the purposes of assisted dying eligibility. There may also be uncertainty if the person is refusing treatment for the anorexia. Anorexia is not a physical condition, but because advanced anorexia can lead to physical conditions which lead to death, it can become

a complex physical and psychiatric illness.

The first issue, which has been a point of conflict, is whether it is ever appropriate to regard anorexia nervosa as a terminal condition. It has been suggested that in a very small minority of cases it is right to do so, [269] however, others have argued that it is extremely harmful to do so because it sends a damaging message to a vulnerable group of patients. [270]

There have been cases involving assisted dying for people with severe anorexia in jurisdictions, e.g. the Netherlands, that do not require terminal conditions, e.g., Esther Beukema, which was reported in the Telegraph. [271] There have also been reports of cases in places that purport to require terminal diagnosis,[272] but we have not found any authorised reports from those jurisdictions.

Assessing the Jersey definition (a physical condition expected to cause death within the required period of 6 or 12 months), it seems possible that a person with advanced treatment-resistant anorexia nervosa that has caused serious physical decline that will lead to death unless treated, could potentially qualify within the eligibility criteria. Because the Jersey law also stipulates that the illness/condition need not be

untreatable if the person believes that they would not be able to bear the suffering that the treatment is expected to cause them', it appears to potentially allow the so-called anorexia loophole'. It may be that the States Assembly intends this and wishes to adopt a flexible approach on the basis that it is compassionate to do so, but if this possibility has not been fully considered, and if there is concern about ambiguity and flexible interpretations of the law, this issue could be addressed by adopting a more restrictive approach to the health criteria.

In summary, although the health criteria indicate that terminal illness expected to cause death in six or twelve months is required, the draft law provides a flexible characterisation. By allowing the refusal of potentially life-extending treatment deemed by the person to involve unbearable suffering, the law potentially allows a flexible interpretation of terminal illness'. This could lead to people who have rejected treatment that could extend life or even lead to a full recovery being eligible. It could also allow people with advanced anorexia nervosa (and associated physical decline) to become eligible.

Recommendation 25: Consider whether the flexible characterisation of terminal illness, that allows treatment refusal, should be restricted. Given that the States Assembly voted against allowing access for non-terminal conditions (Route 2) in May 2024, they may wish to consider a more restrictive approach that limits access to those with an inevitably progressive physical condition that cannot be reversed by treatment'.

4. Assessment of prognosis

On assessing the patient's life expectancy under Article 25 of the draft law, it is explained that:

An assessing doctor, when predicting an individual's life expectancy (6 months, 12 months in relation to a neurodegenerative condition, or within 14 days or less if overriding the minimum timeframe), must predict the matter based on their medical knowledge and their assessment of the individual. They may also base their prediction on a relevant opinion (for example, where they have sought the opinion of a professional who has expertise in the individual's condition).'[273]

Assessment of prognostication is an inexact science and has been challenged. [274] There are multiple prognostication tools and none have demonstrated accuracy.

Prognostication improves closer to death, with poor accuracy related to assessing prognostication in months. The assumption in the draft law is that prognostication will

not be based upon any results from prognostication tools but, rather, the convergence of two doctors' assessment. These assessments may draw upon other specialist opinions to enhance this assessment. [275] The BMA has suggested that:  

It would be helpful, and reassuring for doctors, to add an additional point to Article 25(2) saying: (c) based on the information available at the time.'

25 (2) The doctor –

1. must predict the matter reasonably and based on their medical knowledge and on their assessment of the individual; but
2. may base their prediction on a relevant opinion that they obtained under Article 31, as allowed by Article 31(3).' [276]

There is a need to be upfront and recognise prognostication is an estimate and not exact; otherwise, this is likely to lead to challenges to the law where people request an assisted death, are deemed eligible, but then do not ultimately choose assisted dying and live beyond their assessed prognosis.

Recommendation 26: Add the additional wording based on the information available at the time' to Article 25, as suggested by the BMA.

Recommendation 27: Ensure that the training for assessing doctors covers the lack of clarity in prognostication.  

5. Assessment of expected suffering

In cases where the health criteria for eligibility is focused on expected rather than present suffering, the assessing doctor must satisfy themselves that the person would not be able to bear the suffering that the condition or treatment is expected to cause them. [277] In reasonably predicting this, an assessing doctor considers whether the individual believes that they would not be able to bear the expected suffering. The assessing doctor must satisfy themselves only that the individual believes this and, if the assessing doctor believes otherwise, they must ignore their own belief.[278] However, the assessing doctor is required to tell the individual of their view that the individual's belief is wrong. [279] This was not set out in P.18/2024, but has been added further to stakeholder feedback.

Looking to other jurisdictions, the approach under Jersey's draft law is most similar to New Zealand and Victoria, Australia, in requiring both terminal illness and patient experience or expectation of suffering. The difference is that both New Zealand and Victoria only include suffering that is already occurring. In New Zealand, under the End of Life Choice Act 2019, in addition to a terminal illness that is likely to end the person's life within six months', [280] the law requires that the person:

 experiences unbearable suffering that cannot be relieved in a manner that the person considers tolerable'.[281]

In Victoria, under the Voluntary Assisted Dying Act 2017, in addition to the requirement of an incurable' disease, condition or illness expected to cause death within six months (s.9), there is also a requirement that this:

is causing suffering to the person that cannot be relieved in a manner that the person considers tolerable'[282]

The Jersey law is distinctive, however, because it also accepts anticipated suffering. The adaption from P18/2024, to require' a doctor to tell a person that their belief (that they will not be able to tolerate the suffering) is, in the doctor's opinion, mistaken, does not shift this assessment of suffering to an objective test. It merely places an obligation on the doctor to tell the person that their anticipation of unbearable suffering is, in the doctor's view, not necessarily objectively correct. It does not mean the doctor may reject the person's belief and prevent them from seeking assisted dying on that basis.

Consequently, this is a change from P.18/2024 that has ethical implications rather than altering the legal position on the (subjective) assessment of anticipated suffering

ethical rather than a legal issue. The ethical implications of this are not problematic because, in telling a patient that the suffering will not be as bad as a person anticipates, a doctor would be aiming to reassure and reduce distress about the

end of life. Provided that the doctor is acting reasonably and in good faith, in giving patient information about the nature of the anticipated suffering from an expert clinical perspective, the change from P.18/2024 seems ethically justifiable.

See also the brief discussion related to the assessment of expected suffering and prognosis in the Appeals section above.

6. Mode of administration: Implications for assisted dying practitioners

At Step 6 of the process, the Administering Practitioner and the individual are required to agree on a care plan that records the individual's preference for their assisted death, including who will administer the drugs (self-administration or practitioner administered) and how they will be administered (for example, orally or by IV)'.[283] As noted earlier, research and data demonstrate that, where both practitioner - administered and self-administered assisted dying are lawful, the majority of people opt for a practitioner-administered assisted death. [284] We note that the assisted death may be easier on the administering practitioner if the drugs are self-administered.[285] In jurisdictions with lower rates of assisted dying, these can be associated with greater

use of self-administered assisted dying rather than practitioner-administered.[286]

4. Setting out the system of administration and roles in the Assisted Dying Service

The table in the report accompanying the draft law provides a helpful visualisation of the steps involved in the proposed assisted dying process. However, it would also be very helpful to have a visualisation of the whole system, including the reviews, the steps and how the different roles within the Assisted Dying Service fit and work together.

Recommendation 28: Create an organogram for the whole assisted dying system and roles in the Assisted Dying Service.

5. Staff refusal

According to Article 36 of the draft law, a person acting in a specified capacity may, on any grounds, refuse the specified participation in assisted dying unless an exception applies. An administering practitioner has the right to refuse to administer the approved drugs to an individual and may opt to only support self-administration. However, the administrating practitioner cannot refuse to administer approved drugs (themselves) to

an individual if they previously agreed to do so in the individual's care plan, although

they can refuse to do so in the first instance. [287] It is stated that this is to avoid undue distress to an individual if an administering practitioner were to unexpectedly exercise their right to refuse in the hours and minutes immediately preceding death'. [288] And an assisted dying practitioner, a Certifying Doctor and a Care Navigator cannot refuse to participate on the basis that they have opted-in to be an assisted dying practitioner'.[289]

The existence of these exceptions means that the right to refuse to participate is not an absolute right. Moreover, in practice, it would be very difficult to insist that an assisted dying practitioner had to perform an act. The GMC guidance permits a broad potential to refuse to participate in any treatment based on conscience (save when it's necessary in an emergency e.g., abortion, so any law that suggested otherwise would conflict with the ethical guidance. [290] Other regulators (NMC, AHCPC) provide for a similar approach to refusing to participate, and so the draft law potentially conflicts with the ethical guidance. [291]

Nobody knows how they will act until the moment. This will be especially true if this is the first time someone performs an assisted death. It also might be more challenging in some situations than others – for example, where young children are present. The impact on health care professionals who know the patient and have been caring for them over a period of time can be profound. This needs to be taken into consideration and they should be allowed to refuse. While the law was introduced to prevent further anxiety for patients and families, it may result in increased anxiety and/or refusal from assisted dying practitioners.

Question: If assisted dying practitioners refuse, what happens to them? Are they removed from the assisted dying practitioner register?

Although the draft law does not limit the right to refuse to directly participate in assisted dying, similarly to assisted dying laws elsewhere in Australian states, [292] it sets out activities that:

a. constitute participation, so may be refused (for example, giving patients information

about assisted dying; giving a relevant opinion to support an assisted dying assessment; being present at the administration of the approved drugs)

2. do not constitute participation, so may not be refused (for example, caring for the individual's body after death; reserving an appointment time for them; providing usual care and treatment; cleaning the Services offices).'[293]

The list of activities that are not participation in assisted dying (and so are not covered by the right to refuse) also includes acting in the role of a member of the Committee or the Review Panel'. [294] According to its submission to the Assisted Dying Review Panel, the BMA is satisfied that most of the activities stated under Article 35(2) as not amounting to participation appear reasonable and sufficiently distant from the assisted dying process itself to fit within that category'. But in the BMA's view:

The exception to this, however, is: 37(c)(ii) – acting in the role of a member of the Committee or the Review Panel. Although this is not participating in a particular case, or the actual process of an assisted death, these roles require a high degree of involvement in the broader provision of assisted dying. This activity therefore seems fundamentally different to the other activities listed, where the fact the individual is seeking an assisted death is, to a large extent, incidental to the service they are providing. Including these roles as an example of something that is not "participation" seems to distort the reasonably clear line between what type of activities constitute "participation" and which do not; this unnecessarily introduces ambiguity into this important provision which could lead to further questions about interpretation. We believe that some of our members would feel morally compromised by "enabling" the process to this extent; and would be very uncomfortable with reviewing the details of individual deaths; and would perceive acting as a member of the Committee or Review Panel as "participation" in assisted dying. We would therefore wish to see 35(c)(ii) removed from this list.'[295]

Given that the Assisted Dying Service could not operate without the Review Panel, these roles are integral to the Service and thus, we agree that they can be seen to be enabling', even if not participating' in an actual assisted death.

Recommendation 29: Remove clauses stating that the administering practitioner cannot refuse to administer approved drugs (themselves) to an individual if they previously agreed to do so, and that an assisted dying practitioner, a certifying doctor and a care navigator cannot refuse to participate on the basis that they have opted-in to be an assisted dying practitioner. Replace with:

i.a. A clause that requires that the patient should be informed that there is a

chance that the administering practitioner or witness may not feel able to conduct the death on the day; and

b. state in this new clause that, in the event of this occurring, every effort will be made to identify an alternative provider;

OR

ii: State in this new clause that, for practitioner-administered assisted dying, a second administering practitioner must attend to either act as the administrator or witness.

Recommendation 30: Obtain feedback from all the relevant professional bodies regarding the issue of staff refusing to participate on the basis that they have opted-in to be an assisted dying practitioner.

Recommendation 31: Reconsider whether the roles of a member of the Committee or the Review Panel should be included as examples of a role that is not participation in assisted dying (and so would not be covered by the right to refuse) under Article 37.

6. Protection to health professionals who refuse to participate from employment detriments

As stated in the report accompanying the draft law:

In accordance with feedback from the BMA, and in common with legislation in New Zealand and the Isle of Man, the draft law protects employees and business partners (for example, partners in a GP Practice) who exercise their right to refuse, from employment detriments, such as being sacked, overlooked for employment, promotion etc. Equally, it also protects employees and business partners who do participate in assisted dying.'[296]

Article 96 enables the Assembly, by Regulations, to provide for civil remedies where an employee or business partner has suffered an employment detriment because they refused to participate or did participate in assisted dying. It is anticipated that the Minister will present these Regulations to the Assembly before the law comes fully into force ...' [297]

In abortion, General Practitioners (GPs) who have a conscientious objection to discussing or participating in abortion-related care are not legally required to inform their practice, but professional guidance strongly advises that they do. This is to support patient access to care.

Question: Should there be a similar statement about assisted dying?

The BMA is positive about Article 38 of the draft law that sets out the employment and partnership protection (for involvement or non-participation), but also identifies a potential gap in this protection:

We are very pleased to see this important protection included in the draft law. There is, however, a gap that needs to be filled. The current wording does not appear to extend to self-employed practitioners, such as GP partners. For example, a doctor who works three days a week as a GP and is also contracted to provide services for the Jersey Assisted Dying Service would not appear to be protected if they applied to be a partner in another practice and were rejected because of the other partners' opposition to assisted dying. We would like to see this provision extended to cover those who work outside an employer-employee context.'[298]

We agree that this would bring added protection and would clarify the extent of the protection offered by the draft law.

Recommendation 32: consider extending Article 38's protection to self-employed practitioners.

Recommendation 33: Ensure adequate training is given to assess what constitutes

a refusal of administration and consider if any tools currently used with non-verbal people are appropriate.

7. Clarification on need not to act to preserve life' after the approved drugs have been administered

The draft law provides that AFTER the approved drugs have been administered, a person need not act to preserve the individual's life if the individual has not requested that. [299]

Is need not act' clear enough? Trained assisted dying practitioners will be aware that they do not have a duty of care to preserve life. However, family members may become distressed if the death is prolonged and may call the ambulance service. Ambulance staff will not be trained assisted dying practitioners. Need not' might be construed as: the choice is yours if you want to preserve life' ie it isn't ruled out. This would be very challenging if a family member is asking the ambulance staff to preserve life.

Recommendation 34: Consult with the Jersey ambulance service to clarify terminology of need not act to preserve life under Article 10(4) to remove any ambiguity.

8. Place where the assisted death takes place

According to the report accompanying the draft law, the place of assisted death must be approved by the Administering Practitioner.[300]

Question: Will there be wholesale approval of certain institutions i.e. Jersey hospital/ hospice/care home or would this be applied for?

Question: A care home maybe seen as both an institution and a patient's home – given this, who has the right to refuse on the premises?

It is also stated that Where the place is a care home that is not provided by Health and Care Jersey, the provider or manager must have agreed that the assisted death may be carried out there.'[301]

There are cases in Canada where patients have had to be transferred home against their preference to have the assisted death that they desire, which can only be distressing for patients and their families, and something to avoid if possible. This may result in earlier deaths. [302]

Recommendation 35: Develop training for care home staff, including managers. Training should include a focus on understanding that transferring people late can be distressing for residents, especially if they consider the care home to be their home.

9. Review

The Review Panel will be required to review each assisted death that is carried out and also, if requested by the Committee, any individual's assisted dying process that ended before their assisted death (because, for example, the individual withdraw their request; the request was not approved; the person died of natural causes). [303] Most countries include a post-death' review. However, under the TIA Bill in England and Wales, the UK Government is proposing a pre-approval role for a panel prior to the assisted death. This would thereby allow for a prospective review. Retrospective review cannot stop potentially dangerous cases going ahead, but could act as a place for future learning,

and, as noted in the report accompanying the draft law, also supports immediate identification of suspected malpractice and, as such, [is] critical to safeguarding

people'. [304]

Question: Has there been consideration of a panel to review the request prior to the final step?

This Article also relates to comments by the BMA on staff refusal.[305] The cost of setting up the review panel with be high, given the training and resourcing needs. Thus, as there is only expected to be a small number of cases, it might be a more effective use of these resources if, in the early years of the introduction of the law, all cases are reviewed.

Recommendation 36: Consider including a review of all assisted dying requests (whether resulting in an assisted death or not) for the first three years.  

PROPOSED END-OF-LIFE CARE LAW AND THE PALLIATIVE AND END OF LIFE CARE STRATEGY

1. Proposed End-of-Life Care Law

The main proposition:

• to agree that the Minister for Health and Social Services should be required by law to provide for end-of-life services in Jersey'[306]

There is a lack of clarity in terminology between palliative care and end-of-life – they seem to be used interchangeably:

End-of-life care is palliative care provided to a person who is likely to die within one year. Palliative care, as defined by the World Health Organisation, is an approach to care that improves the quality of life of patients - and their families - who are facing problems associated with life-limiting illness. Palliative care / end-of-life care prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems whether physical, psychosocial or spiritual.'[307]

It will thus be necessary to clarify whether the proposition is to provide palliative care services only in the last year of life (in the UK defined as end of life care) or broader to encompass palliative care. The WHO definition [308] uses the phrase life threatening rather than life limiting. This is not restricted to the last year of life. The International Association of Hospice and Palliative Care (IAHPC) has a different definition: Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness, and especially of those near the end of life.'[309] There has, however, been controversy about the new definition from the IAHPC, and also the differences between life-limiting and life-threatening.  

Notably, the UK Government's intention to develop a Palliative Care and End-of-Life Care Modern Service Framework for England (planned for Spring 2026) is outlined in the written ministerial statement published on 24 November 2025. This combines palliative AND end-of-life, and we now quote this (at length):

the Government is developing a Palliative Care and End of Life Care Modern Service Framework for England, with a planned publication date of Spring 2026. This will be aligned with the ambitions set out in the recently published 10-Year Health Plan, which prioritises shifting care out of hospitals and into community settings to ensure personalised, compassionate support for individuals of all ages and their families.

This government recognises that there are increasing numbers of people living with multiple complex conditions, that we have an increasing ageing population and that there are tens of thousands of children and young people with life-limiting or life- threatening conditions.

We acknowledge the significant challenges currently facing the sector, including:

• Delays in early identification of individuals approaching the end of life.

• Inconsistencies in commissioning practices across integrated care boards (ICBs).

• Workforce challenges in both universal and specialist services.

• Gaps in 24/7 palliative care provision.

• Limited uptake and integration of personalised care and support planning, including advance care planning.

In recognition of these challenges, we are prioritising this cohort, as referenced in NHS England's Medium Term Planning Framework, which commits to an immediate focus on reducing unnecessary non-elective admissions and bed days from high- priority cohorts, including those at the end of life.

A Palliative Care and End of Life Care Modern Service Framework will drive improvements and enable ICBs to address these challenges through the delivery of high-quality, high-value, personalised and equitable care.

Consequently, the Modern Service Framework will put in place a clear and effective mechanism to deliver a fundamental improvement to the care provided. This will enable adoption of evidence-based interventions that are proven to make a difference to patients and their families. Examples include earlier identification of need, care delivered closer to home by integrated generalist and specialist teams

and strengthened out-of-hours community health support, including dedicated telephone advice.

We have already begun to engage with sector stakeholders on how to improve access, quality and sustainability in palliative care and end of life care and will continue to engage with them to shape and deliver this vision. We want a society where every person receives high-quality, compassionate care from diagnosis through to the end of life, and we recognise that access to high-quality, personalised palliative care and end of life care can make all the difference to patients and their loved ones.'[310]

It would be unusual to only have a law on end-of-life care.

The proposed law appears to be a response to the developments regarding assisted dying, with large sections devoted to the assisted dying draft law. It would be more aspirational to focus on palliative and end-of-life care as a need rather than just because assisted dying is being introduced.

The IAHPC states that key elements for Governments on policy for palliative care include:

1. Adopt adequate policies and norms that include palliative care in health laws, national health programs and national health budgets;
2. Ensure that insurance plans integrate palliative care as a component of programs;
3. Ensure access to essential medicines and technologies for pain relief and palliative care, including pediatric formulations;
4. Ensure that palliative care is part of all health services (from community health- based programs to hospitals), that everyone is assessed, and that all staff can provide basic palliative care with specialist teams available for referral and consultation;
5. Ensure access to adequate palliative care for vulnerable groups, including children and older persons;
6. Engage with universities, academia and teaching hospitals to include palliative care research as well as palliative care training as an integral component of ongoing education, including basic, intermediate, specialist, and continuing education.

Key areas across all end of life laws cover:

1. Right to palliative care – to support access to it (link to Human Rights)
2. Need for Advance directives and Living Wills
3. Equitable access
4. Role of health care providers and their training [311]

As a comparator, the UK law addresses through statutory law and policy:

1. Right to Palliative Care  
   1. Health and Care Act 2022
   2. Commissioning of ICBs
2. Statutory guidance for ICBs
   1. How ICBs should implement palliative care
   2. Handbook for ICBs
3. Addresses Inequalities

England's framework relies on statutory commissioning duties and guidance but lacks a standalone law guaranteeing individual rights to palliative care. Jersey's proposed law offers a clear, enforceable statutory right to end-of-life care, with detailed provisions for care standards, settings, and patient inclusion. In our view, Jersey's approach is more legally robust and patient-centred, especially in the context of assisted dying legislation.

According to the Addendum to P.65/2025, assuming the draft law is adopted in December 2025, Assembly Members will not take the decision to bring the adopted law into full force until after the anticipated 18-month implementation period (i.e. c. July

2027). As such, they are not required to be satisfied as to there being an improvement in palliative care until that point, however, the information set out in this report will provide the Assembly assurance as to the progress currently in train. [312]

Questions: Why delay implementation until after the Assisted Dying law? Could earlier adoption strengthen safeguards and patient support?

Why include so much on Assisted Dying? Consider the need for a law on palliative and end of life care outside of assisted dying, as exists in other jurisdictions

Recommendation 37: Clarify the scope of the proposed end-of-life care law – should the law cover only end-of-life care (thus the final year of life), or broader palliative care?

Recommendation 38: Engage stakeholders - to obtain feedback from the Jersey Care Commission and other providers on proposed provisions under the end-of-life care law, if this has not already occurred.

Recommendation 39: Make the proposed end-of-life law less prescriptive and more aspirational: consider WHO and IAHPC guidance about comprehensive integration.

2. Palliative and End of Life Care Strategy

Overall, the current state of palliative care is good, with the addition of the Living Well team and there are good outcomes.

The Living Well Service is, however, quite prescriptive – does Jersey want something so prescriptive? If new research comes out suggesting strengths in other services, will this not pose a limitation? The UK End-of-Life Care Strategy included the national rollout of the Liverpool Care Pathway, which at the time lacked an evidence base. It also lacked a national implementation strategy. The pathway was subsequently discontinued largely due to public pressure and the available evidence, although later research evidence supported its use. [313] One of the IAHPC principles recommends:

1.  Ensure that palliative care is part of all health services (from community health- based programs to hospitals), that everyone is assessed, and that all staff can provide basic palliative care with specialist teams available for referral and consultation

If this more generic description were used (as above), then the Living Well Service could provide an example of such a service.

According to the Strategy, A particular focus of the EOL Partnership was, over the 4-year course of the strategy, to deliver the changes necessary to enable more people to die in their preferred place. In 2021 a significant number of people who were receiving care from Jersey's Specialist Palliative Care Team were not able to die in their preferred place.'[314]

Rather than focussing on place of death, place of care in the time leading up to the death can be a more meaningful outcome. [315]

Recommendation 40: Consider broadening the Palliative and End of Life Care Strategy's focus from just place of death to place of death and care.

1. Strategy Outcomes

Outcome 1 refers to promoting advance care panning. There are very low levels of advance care planning internationally and in the UK. Advance care planning was designed for people who can no longer be involved in shared decision-making. It is critical that all patients are informed about their condition, discuss their goals of care and make shared decisions to plan for their future care. This may include advance care planning discussion and the recording and sharing of plans in case they lose capacity. The benefit of advance care planning alone is in doubt. [316] The focus is now more on preparing for the future and making plans in tandem with ongoing shared decision making. [317] Most people will need to make plans for their death whether they lose capacity at the end or not. Preparedness is key.

Recommendation 41: Change the Palliative and End of Life Care strategy outcome 1 to People in Jersey who need palliative and / or end of life care will be seen and treated as individuals who are encouraged to be involved in shared decision

making about their care which may lead to advance care plans'

2. Funding

It seems that this is similar to the UK, with a large proportion coming from charity sources, although with the additional £3 million now. Why doesn't this increase from 2026?

Question: is this funding proposition too detailed and will it go out of date? Does that matter if it is only in the report but not the Strategy itself?

CROSS-BORDER IMPLICATIONS

Given the small size of the island of Jersey and its pool of medical professionals, the cross-border implications for UK-based medical professionals in particular are important. Both the GMC and the BMA raise concerns about this in their submissions. The GMC states:

We anticipate that consideration will also need to be given to cross-border issues. For example, a number of Jersey residents are referred to hospitals in the UK for treatment when specialist care isn't available in Jersey, the potential implications of this in this context will require exploration and clarification.' [318]

The BMA makes a number of points, all of which we include here as important questions to be addressed:

Patients from Jersey receiving specialist treatment in England. We are aware that some patients from Jersey receive specialist care in England. Those specialist doctors, who are treating patients (in England) who are eligible for – and may wish to choose – assisted dying in Jersey, would still be bound by the terms of the Suicide Act 1961. This means that if they do, or say, anything (whilst in England) that might be perceived as encouraging or assisting' their patient to have an assisted death in Jersey, they would be committing a criminal offence.

We have been in contact with the Director of Public Prosecutions and the General Medical Council about this issue to try to establish whether, in those circumstances, our members would be likely to face criminal or regulatory sanctions. Even if they would not, the BMA cannot advise its members to commit a criminal offence.

We have tried to seek an amendment to the Terminally Ill Adults (End of Life) Bill at Westminster to extend the protection of that Bill to include doctors providing assistance under legislation in other parts of the UK or Crown Dependencies. Such an amendment has thus far, however, been deemed to be out of scope. Given the

very significant implications for our members, we are asking the UK Government to find a way (either through the current Westminster Bill or otherwise) to ensure that doctors who find themselves in this situation are not expected to commit a criminal offence in order to support their patients.

Doctors from England could travel to Jersey to carry out assessments or to give a formal opinion for a patient who is seeking assisted dying in Jersey. Wider discussions that arise in other consultations, about end-of-life care, which could touch upon assisted dying would, however, remain very risky for our members and could lead to such discussions being actively discouraged or curtailed – to the detriment of those patients.'[319]

The report accompanying the draft law explains that, whilst P.18/2004 had anticipated that UK-based professionals could provide assessing doctors with relevant opinions whilst in the UK, further discussions with the GMC, the BMA and the UK's Ministry of Justice have highlighted the real risk that offences may be committed under the Suicide Act 1961 (England and Wales) in such cases. However, where a UK-based professional travels to Jersey to undertake an assisted dying assessment or provide a relevant

opinion in accordance with the Jersey Law, they would not commit an offence under the law in their own jurisdiction. Also, to conduct an assessment in Jersey, a doctor would need to be a trained assisted dying practitioner. It is therefore clear that:

• UK-based doctors cannot take on the assessment role or provide opinions whilst based in the UK.

• Only UK-based doctors visiting Jersey who have had the Jersey training can take on the role of assessing doctor.

• UK-based doctors should be able to provide information relating to treatment, diagnosis etc in a generic way but not with the express use for assisted dying

It is specified in the draft law that, whether meetings are held in person or electronically, each person must be in Jersey unless an Order requires or allows the person to be in another place. [320] This allows for an Order-making power so that if the UK position changes, the law can provide for meetings to be held in the UK'. [321] Whilst this clarifies the situation to an extent, we recommend that it be made absolutely clear in the draft

law that a UK-based doctor should not be asked to provide information for the express use for assisted dying.

Recommendation 42: That it be expressly stated in the draft law that UK-based doctors should not be asked to take on the assessment role/provide opinions or provide information with the express use for assisted dying, whilst based in the UK.

DOES THE DRAFT LAW ALIGN WITH HUMAN RIGHTS LAW?

We have reviewed the human rights law Notes' provided within the report. [322] We agree with the conclusion that the draft law is broadly compatible with the European Convention Human Rights in respect of Article 2 (right to life) and Article 8 (right to private life and family life) with the proposal to allow assisted dying within a carefully constructed legal regime with safeguards. As the report confirms, the European Court

of Human Rights relies on the margin of appreciation doctrine, which allows flexibility in relation to the acceptance of both lawful assisted dying [323] within a regime with safeguards for vulnerable people, or alternatively, a blanket ban on assisted dying [324] within member states. Lambert v France 337 highlighted how the margin of appreciation is particularly important and especially wide when addressing complex and sensitive moral issues at the beginning and end of life, and there is no consensus in Europe on assisted dying. The question of whether any lawful model will fall within the margin of appreciation, however, will depend on whether there are appropriate safeguards.

While we agree with the broad position of the human rights note in the report, there is scope for greater consideration of Articles 2 and 8, and importantly, there are additional Convention rights which may be engaged on the issue of assisted dying beyond those identified in the Notes'. Given the time constraints of our advisory role, we do not have capacity here to provide a very detailed assessment of all the numerous potential human rights implications, so we have highlighted the most relevant issues that could arise. Other Convention rights that have been identified as having a potential relevance have been considered in the UK by the Terminally Ill Adults (End of Life) Bill: equality impact assessment. 338

Article 2 has been applied in this context in the case of Mortier v Belgium, 339 when the family of a deceased woman argued that her death had violated Articles 2 and 8. The general approach in Belgium, which is more liberal than that proposed in Jersey, was held to be broadly compatible with the ECHR. However, the ECtHR held that there was a procedural violation under Article 2 in relations to the criminal investigation of the doctor who performed the euthanasia' (practitioner administration). The ECtHR held that states must ensure:

the provision of appropriate and adequate safeguards to prevent abuse and thus ensure respect for the right to life. In this connection, the court also notes that the United Nations Human Rights Committee has held that euthanasia does not in itself constitute an interference with the right to life if it is accompanied by robust legal institutional safeguards to ensure that medical professionals are complying with the free, informed, explicit and unambiguous decision of their patient, with a view to protecting patients from pressure and abuse.'340

We have discussed safeguarding and whether the draft law provides sufficient protection in an extensive section above. While we have highlighted some areas for consideration in this part of the report, we are satisfied that the safeguards do meet the standard necessary as outlined in human rights jurisprudence based on comparisons with other ECHR Member State jurisdictions that permit a more liberal model of assisted dying with fewer safeguards, e.g., the Netherlands, Belgium and Switzerland.

We have also discussed reviews of assisted deaths above, which raises the human rights obligation in respect of monitoring assisted dying and providing a robust procedural approach to recording death and reviewing cases of assisted dying. In Mortier, the court recognised that the state's duty to safeguard the right to life involves, in the event of death, the procedural positive obligation to have in place an effective independent judicial system. [325] The court also stressed the need for an independent post-death review system. [326]

Also concerning post-death measures, the ECtHR has emphasised that everyone has a right to have access to information concerning private and/or family life in the context of death of a family member. See, for example, Lozovyye v Russia 343 or Jovaovic v Serbia, 344 which concerned death registration. The draft law will provide a transparent record of

the cause of death, in contrast to jurisdictions that do not record that individuals had an assisted dying.345 This states that the death certificate will record that 'death was

caused by administration of the approved drugs'. However, the disease or conditions

and 'antecedent causes' will also be recorded, which, therefore, provides the

information necessary to fulfil this obligation.

The criminal provisions within the draft law must also comply with Article 2 principles, thus ensuring that the Jersey Criminal Justice system responds in a timely and appropriate way after possible breaches are identified is crucial. For example, in Mortier, one of the ECtHR's criticisms of the Belgium regime was that the criminal investigation (after the family of the deceased complained) was slow and lengthy, taking over four years. 346

Article 3 (prevention of torture, inhumane or degrading treatment) has been raised in legal challenges concerning assisted dying. The case of Pretty v UK347 concerned the State's refusal to allow the applicant's husband to help her to end her life, which it was argued placed the applicant in a position of suffering from her illness (motor neurone disease). This was rejected by the ECtHR. The TIA Bill equality impact assessment suggests that a different argument might be attempted; that suffering may be caused by a practitioner administering or assisting a person to self-administer the drugs. 348 This might feasibly be arguable if the process, e.g., the provision of drugs caused significant pain, or significant emotional distress that constituted a breach of a person's physical or psychological integrity.[327] There is, however, no ECtHR jurisprudence that has

supported a violation of Article 3 in the context of assisted dying. The equality

assessment concludes that the combination of safeguards' in the TIA Bill means that

there could be no breach of a person's integrity in a way that would support a violation

of Article 3. The Jersey draft law has similar safeguards, with the notable omission of a multi-disciplinary panel approval stage following the two medical assessments. [328] Also, no successful Article 3 arguments have been supported by the ECtHR in any other

lawful jurisdiction, and so we anticipate that the Jersey law is compatible with Article 3.

Article 5 (Deprivation of liberty) may be relevant to the arrest, detention and imprisonment of a person suspected, prosecuted and convicted of an offence under the draft law. Article 5(1)(a) provides an exception for lawful detention following a conviction by a competent court. This discussion, therefore, links to the criminal justice system in Jersey, and our Criminal Offences section regarding the sentencing limits for the new offences. After reviewing the jurisprudence of the ECtHR, it seems very unlikely that any challenge would succeed, because the main basis for establishing a violation of Article 5 in this context seems to concern indeterminate sentences or continuing to detain an individual after the period of the tariff. For example, see James, Wells and Lee v UK. 351

Article 6 (the right to a fair and public hearing within a reasonable time by an independent and impartial tribunal established by law) invites scrutiny of the appeal provisions against a decision to allow or refuse assisted dying, and also the way that any trials for offences under the draft law are arranged and conducted. 352 Assuming the latter will be arranged and conducted according to established principles within the Jersey criminal justice system, we assume these to be Convention-compliant.

Article 7 (prohibits the retrospective application of the criminal law and requires any offences and the corresponding penalty to be clearly defined in law) is engaged on the criminal provisions in the draft law. The draft law clearly sets out the offences and penalties, and the risks of retrospective application seem very low in this context.

Article 8: As the report Notes' set out, art 8 is the most important Convention right on assisted dying, with no broad finding of incompatibility either for allowing or not allowing assisted dying. However, there may be scope for challenges which seek to expand the eligibility criteria. For example, allowing only those with a terminal physical condition access to assisted dying and preventing those who do not fulfil that criteria, might be argued to treat two comparable groups differently, thus engaging Articles 8 and 14 (protection from discrimination). There is jurisprudence supporting the contention that treating individuals in 'analogous, or relevantly similar, situations' differently violates Articles 8 and 14. [329]

This argument has been put forward in relation to the TIA Bill; for example, Murray has suggested that limiting eligibility for an assisted death to those with a terminal condition will violate the human rights of people who are suffering unbearably but who are not terminally ill. [330] This argument is linked to so-called slippery slope arguments; that law allowing a certain restricted group, e.g., terminally ill adults, to access lawful assisted dying will be incapable of maintaining the restriction, which will lead to dangerous consequences. The legal basis for this contention is largely founded on a comparison with the development in Canada, when the original limitations of the Canadian law, which allowed MAiD only to those for whom death was reasonably foreseeable, were successfully challenged in Truchon and Gladu v AG Canada and AG Quebec. [331] The challenge succeeded, with the applicants successfully arguing that limiting eligibility to those reasonably expected to die breached the Canadian Charter of Rights and Freedoms [332] regarding the rights of people with a disability whose death is not reasonably foreseeable. However, a counterargument has been made that the

Canadian constitutional position is distinct, and the margin of appreciation in respect of the ECHR means that the same argument would not succeed in respect of ECHR. Martin has contended that although the ECtHR has not been asked to consider whether restricting access to people who are terminally ill violates the rights of those who are also suffering but who are not terminally ill, analogous jurisprudence exists to suggest the distinction would be permissible.[333] Namely, the case of Karsai v Hungary358 indicates that the wide margin of appreciation would extend to permitting a distinction between terminally ill adults expected to die within a specific time frame and, alternatively, others not expected to die soon. In Karsai, the ECtHR held that there are reasonable justifications for distinguishing between individuals receiving life-sustaining treatment who are permitted to refuse such treatment and consequently die, and other individuals who would require active assistance to end their life.

On this basis, we believe that restricting access to individuals who are expected to die within six or twelve months would be acceptable under the margin of appreciation. Article 8 ECHR is a qualified right, with the grounds for exception under 8(2) having been expressly related to the aim of protecting vulnerable people in the context of assisted dying in Pretty v UK.359 While this was in the context of the blanket ban provided by the Suicide Act 1961, it seems reasonable to suggest that the same justification in respect

of protecting individuals who are disabled but not terminally ill may be lawful. Therefore,

the draft law arguably strikes a reasonable and proportionate balance between the competing interests protected by the ECHR.

A further issue where we anticipate there could be possible tension with human rights law is in respect of the provision allowing an appeal by a third party (a 'person with special interest') seeking to prevent a person from having an assisted death after they have been assessed and accepted as eligible, under Article 42 of the draft Jersey law. The first matter that could prove problematic regarding a third party appeal from an Article 8 perspective, is patient confidentiality. According to P.65/2025:

The draft law prohibits people from disclosing information that allows for the identification of an individual who is having an assisted death'[334]

However, this possibility seems to have been anticipated in respect of a person with a special interest and pursuant right to appeal, as Article 29 states that such a person, can only appeal if they are aware of the individual's assisted dying request in the first instance.'

If the third party knew about the assisted dying and the details of the person's terminal illness etc because of a close family or personal relationship in which the person had shared the information, that would obviate the risk of human rights or other violations in respect of healthcare professionals involved in the assisted dying application sharing confidential information. However, any appeal by a third party would presumably proceed without the permission of the person concerned (because they wish to

proceed with their assisted death having been assessed and found to be eligible), and so such an appeal may involve the third party sharing confidential information in a way that potentially breaches the assisted dying law and violates Article 8 of the ECHR. [335] The second potential violation of Article 8 relates to autonomy. Gross v Switzerland [336] and Mortier v Belgium [337] both provide authority that there is an Article 8 right to seek to have an assisted death within a regulated, lawful system. Within such a system, if a person has been assessed and found to be eligible (which necessitates a finding of capacity), to allow a third party to seek to prevent a person from exercising their Article 8 rights in this context may violate Article 8. It may be that if there was a challenge – based on a person arguing their Article 8 rights are violated by such a third party appeal - the ECtHR would find that allowing such a third party right of appeal may fall within the parameters of lawful exceptions in Article 8(2). We have reviewed the jurisprudence and can find no directly relevant cases. Broadly comparable cases, such as Mortier,

involved a third party challenge after the death of the individual. Post-death challenges have therefore involved issues of substantive procedural review rather than third party veto. Since there is no other ECHR member state jurisdiction (note that Queensland, Australia is not a relevant jurisdiction for the ECHR), that allows a third party appeal against a positive decision to allow assisted dying, this is a novel issue.

This novel human rights question concerning third party veto within the appeals processes clearly raises the possibility of an Article 8 ECHR challenge, and so the panel and the States Assembly should be aware of this issue.

Article 9: One very clear application is Article 9 (freedom of thought, conscience and religion). The main issue here is whether people have liberty to act according to their conscience without being compelled by the State to participate in assisted dying

services. For example, on the matter of abortion provision, opposition to abortion has been given Article 9 protection. [338] The question is whether the law strikes a balanced and proportionate approach between the need to protect healthcare professionals'

rights under Article 9 (and Article 14), against the need to protect the Article 8 rights of a terminally ill person who is seeking assistance to end their own life. We have considered relevant provisions within the draft law which may raise Article 9, namely the provisions allowing people to refuse to participate under Article 36, considered above in the

section on Staff refusal. As we have suggested, there is a possible problem with the provision that states that healthcare professionals who have opted in and agreed to administer or assist a person to self-administer the drugs are not permitted to change their mind at a later stage. Article 9 ECHR is not an absolute right and must be balanced against the Article 8 rights of person seeking assisted dying, however, we anticipate that preventing people from exercising their right to change their mind and refuse to participate might be found to violate Article 9.

Article 14 (freedom from discrimination); there is no free-standing right because proving an Article 14 violation is dependent on the breach of another Convention right. For example, as we discuss in relation to Article 8 and the arguments concerning restricting access to assisted dying to terminally ill people. Consequently, while there is scope for an Article 14 violation in the event that another Convention right is violated, as we have explored in this section or our report, we anticipate that the draft law is unlikely to lead to any successful human rights challenges and so is compatible with the ECHR.

See Recommendation 29 above

CLARIFICATIONS

Paragraphs in the report accompanying the draft law – matters for clarification

[47] (p.14): An individual must meet face-to-face with a Coordinating Doctor to make their first request. This will be captured on a first request form. As set out in P.18/2024, during that meeting the Coordinating Doctor will talk to them about assisted dying, and the assisted dying process.

[145] (p.31): The Order-making power does not, however, allow for meetings where a witness is required to place in an electronic format. These meeting must be in person as they provide an important safeguard

This is somewhat confusing and unclear due to the wording in the latter paragraph. We surmise that [145] should read:

Where a witness is required, however, the Order-making power does not allow for meetings to take place in an electronic format. These meetings must be in person as they provide an important safeguard.

Recommendation 43: Correct the wording in [145] of P.65/2025.

TABLE OF LEGISLATION

Belgium

Euthanasia Act 2002. Available at: https://www.ejustice.just.fgov.be/cgi_loi/change_lg.pl?language=fr&la=F&cn=2002052837&ta ble_name=loi#LNK0003 (Accessed: 27 November 2025)

Austria

Sterbeverfügungsgesetz (Death Directive Act) 2021

Australia

Australian Capital Territory

Voluntary Assisted Dying Act 2024. Available at: https://www.legislation.act.gov.au/DownloadFile/a/2024-24/current/PDF/2024-24.PDF (Accessed 17 December 2025)

Legislation Act 2001. Available at: https://www.legislation.act.gov.au/View/a/2001 - 14/current/html/2001-14.html (Accessed 17 December 2025)

Queensland, Australia

Voluntary Assisted Dying Act 2021. Available at: https://www.legislation.qld.gov.au/view/pdf/asmade/act-2021-017 (Accessed 4 December 2025)

Victoria, Australia

Voluntary Assisted Dying Act 2017. Available at: https://www.legislation.vic.gov.au/in - force/acts/voluntary-assisted-dying-act-2017/005 (Accessed: 27 November 2025)

Voluntary Assisted Dying Amendment Bill 2025. Available at: https://www.legislation.vic.gov.au/bills/voluntary-assisted-dying-amendment-bill-2025 (Accessed: 1 December 2025)

Western Australia

Voluntary Assisted Dying Act 2019. Available at: https://www.legislation.wa.gov.au/legislation/prod/filestore.nsf/FileURL/mrdoc_42491.pdf/$ FILE/Voluntary%20Assisted%20Dying%20Act%202019%20-%20%5B00-00-00%5D.pdf (Accessed 27 November 2025)

Canada

Criminal Code of Canada. Available at: https://laws-lois.justice.gc.ca/eng/acts/c-46/section - 241.2.html (Accessed: 27 November 2025)

England and Wales Suicide Act 1961

Terminally Ill Adults (End of Life) Bill (as brought before the House of Lords from the House of Commons). Available at https://bills.parliament.uk/publications/61635/documents/6734 (Accessed 27 November 2025)

Isle of Man

Assisted Dying Bill 2023. Available at https://tynwald.org.im/spfile?file=/business/bills/Bills/Assisted-Dying-Bill-2023- FINAL_Draft%20for_publication_completed_passage_through_Branches.pdf (Accessed 4 December 2025)

Netherlands

Termination of Life on Request and Assisted Suicide (Review Procedures) Act 2001

New Zealand

End of Life Choice Act 2019. Available at: https://www.legislation.govt.nz/act/public/2019/0067/latest/DLM7285905.html (Accessed 4 December 2025)

Oregon, USA

Death with Dignity Act. Available at https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/D EATHWITHDIGNITYACT/Pages/ors.aspx (Accessed 4 December 2025)

Scotland

Assisted Dying for Terminally Ill Adults (Scotland) Bill [as amended at Stage 2], SP Bill 46A. Available at: https://www.parliament.scot/-/media/files/legislation/bills/s6-bills/assisted - dying-for-terminally-ill-adults-scotland-bill/stage-2/spbill46as062025.pdf Accessed 7 December 2025)

Spain

Ley Orgánica de regulación de la eutanasia (Organic Law on the Regulation of Euthanasia)

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APPENDIX 2: Two examples of possible frameworks for identifying coercion and undue influence in the academic research

Buchbinder and Berens identify six key domains' in their framework to determine whether there has been/is undue influence:

1. Capacity: When a person receiving MAID[339] is no longer mentally competent, the burden of proof to demonstrate that there are no undue influences will be higher, to avoid harm to vulnerable groups.'; Competence should be assessed carefully in particular in those whose decision is driven by feeling like a burden on others.';[340]
2. Authenticity: whether a decision aligns with longstanding personal values';[341]
3. Relationship context: the nature of the relationship matters tremendously. How supportive is the relationship? Has care been provided, and if so, has it been provided willingly? It is important to consider whether and how others may gain from a patient's death and if a decision from MAID is substantially controlled by someone else, to rule out coercion and other forms of undue influence.';[342]
4. Having an adequate range of options: If relational factors (such as a threat or ultimatum) preclude a patient from believing that they could make a different decision, their choice cannot be said to be genuinely autonomous ';[343]
5. Financial considerations: Terminally, ill patients may opt to curtail treatment to avoid burdening their families with medical bills relatively affluent individuals may be motivated by a desire to leave a larger financial legacy for their families. Such financial relational influences may be especially difficult to evaluate because they often operate outside of family members' awareness.'[344]
6. Irremediability: it is important to consider whether the patient's suffering might be alleviated through alternative means. If concerns about being a burden are limited to imposing care responsibilities on one's family members, these concerns might be adequately addressed through alternative care

arrangements, such as in-home nursing support or inpatient hospice.'[345]

They conclude that characterising relational influence in MAID is a challenging enterprise even if clinicians consider each of the evaluative domains we present, they cannot eliminate all ethical uncertainty regarding relational influences' on requests for AD.'[346]

Buchbinder and Berens's framework might helpfully be considered alongside Ost and Biggs's proposed assessment of undue influence model for cases of assisted dying. This is based largely on a list of factors set out in California's Elder Abuse and Dependent Adult Civil Protection Act, [347] which includes provisions designed to protect the welfare of older adults [348] and dependent adults. [349] They propose that attention is given to:

• the person's potential vulnerability (evidence of which may include, but is not limited to incapacity, illness, disability, injury, age, education, impaired cognitive function, emotional distress, isolation, or dependency);

• the influencer's apparent authority (evidence of which can include, inter alia, their status as a family member, or a care provider);

• the  influencer's tactics or actions such as the use of coercion or affection, controlling the person's necessaries of life' or interactions with others', and using their knowledge of the alleged victim's burden perception and/or vulnerability.

• whether the desire to have an assisted death is inconsistent with the person's prior

intent. [350]

APPENDIX 3: Example of a coercion offence that includes inducing someone to revoke their assisted dying request

Jersey's draft assisted dying law is unusual in its extension of a coercion offence to someone being coerced or dishonestly induced to withdraw their request for assisted dying.

A recently enacted assisted dying law in one of the Australian states also includes an offence related to inducing someone to revoke their assisted dying request. According

to Section 40 of the new Voluntary Assisted Dying Act 2024[351] in the Australian Capital Territory (ACT):

40 Offenceinducing making or revocation of request for access to voluntary assisted dying

1. A person commits an offence if the person, dishonestly or by coercion, induces an individual into making a request for access to voluntary assisted dying. Maximum penalty: imprisonment for 7 years.
2. A person commits an offence if the person, dishonestly or by coercion, induces an individual into revoking a request for access to voluntary assisted dying.

Maximum penalty: 100 penalty units.'

There is a significant difference in penalties between the coercion offence as related to making a request and revoking a request under Section 40 of the ACT law: 7 years imprisonment for the former as compared to a fine for the latter.[352] In contrast, the maximum sentence that can be imposed for the coercion offence that would occur when someone is coerced or dishonestly induced to withdraw their request for assisted dying in Jersey would be 14 years imprisonment.

a small number of redactions have been made to the report relating to the names of medications that can be used for an assisted death and dosages.

[1] States of Jersey, Assisted Dying Proposition, P.18/2024 (2024).  

[2] [89.b], P.65/2025, p.20.

[3] Huxtable, R, Lemmens T and Mullock, A, Assisted Dying in Jersey Ethical Review Report' (2023), chapter 6.

[4] Ibid., 6.12.

[5] Ibid., p.76.

[6] Ibid., discussed at [6.13].

[7] Aj, C., & Vn, N. (2018) The Oral MAiD Option in Canada Part 1: Medication Protocols Review and Recommendations A Canadian Association of MAiD Assessors and Providers (CAMAP) White Paper on Oral MAiD.

[8] The abbreviated term used in Canada for Medical Assistance in Dying.

[9] Health Canada (2024) Fifth Annual Report on MAiD in Canada, 2023, p.17.

[10] Willmott, L., White B.P., Haining, C.M. (2024) Review of the Voluntary Assisted Dying Act 2019 (WA): Research Report, p.57. In Queensland, between1 July 2024 to 30 June 2025, 73 per cent (779) of 1072 people died from practitioner administration of a voluntary assisted dying substance, and 27 per cent

(293) died following self-administration of a voluntary assisted dying substance: Queensland Voluntary Assisted Dying Review Board (2025) Queensland Voluntary Assisted Dying Review Board Annual Report 2024–2025  p.17.

[11] A practitioner administration permit in respect of a person specified in the permit authorises the co - ordinating medical practitioner for the person, for the purpose of causing the person's death to

possess, use, and administer in the presence of a witness, the voluntary assisted dying substance to the person' when, inter alia, the person is physically incapable of the self-administration or digestion of the voluntary assisted dying substance': Victoria's Voluntary Assisted Dying Act 2017, s.46(c)(i). See also s.48(3)(a): (3) The co-ordinating medical practitioner must not apply for a practitioner administration permit unless the co-ordinating medical practitioner is satisfied that(a) the person is physically

incapable of the self-administration or digestion of an appropriate poison or controlled substance or drug of dependence '

[12] Victoria State Government (2025) Voluntary Assisted Dying Review Board Annual Report July 2024 to June 2025, p.28.

13 2023-2024 data: 111 practitioner-administered permits and 486 self-administered permits; 2022-2023 data: 82 practitioner-administered permits and 403 self-administered permits.

[13] Assisted Dying Review Panel's meeting with the Minister on 19.11.25.

[14] A number of jury members stated that euthanasia should be available as a fail-safe in the event that self-administration did not work, and where the person was unable to self-ingest. Involve (2021) Should Assisted Dying be Permitted in Jersey, and If So, Under What Circumstances? Final Report from Jersey Assisted Dying Citizens' Jury', p.55.

[15] Ibid.

[16] Assisted Dying Review Panel's meeting with the Minister on 19.11.25.

[17] Oregon Health Authority (2024) Oregon Death with Dignity Act Data Summary, p.21.

[18] Victoria's Voluntary Assisted Dying Act 2017, ss.20(1)(c) and 29(1)(c), with identical wording to be found within Western Australia's Voluntary Assisted Dying Act 2019 (s.16(1)(e)), for example. This can be compared with the longer-standing Death with Dignity Act in Oregon, which simply requires that the attending and consulting physicians must have determined that the person has voluntarily expressed his

or her wish to die'. Chapter 127, 127.805 §2.01.

[19] [1993] Fam 95, 113 CA.

[20] [2002] EWHC 36 (Fam), [28]. The judgment was confirmed in the Court of Appeal: [2003] EWCA Civ 565.

[21] Birks, P. (2004) Undue Influence as Wrongful Exploitation', Law Quarterly Review, 120, pp. 34–37.

[22] Thompson v. Foy [2009] EWHC 1076 (Ch), [101] ( Lewis on J). Craigie presents various understandings of undue  influence  in  her  considered  account  focused  on  undue  influence  and  people  with  mental disabilities:  Craigie, J. (2021) Conceptualising "Undue Influence" in Decision-Making Support for People with Mental Disabilities', Medical Law Review, 29(1), pp. 48–79. See also Chen-Wishart, M. (2006) Undue Influence: Beyond Impaired Consent and Wrongdoing Towards a Relational Analysis', in Burrows A. & Rodger A. (eds.) Mapping the Law: Essays in Memory of Peter Birks. Oxford: Oxford University Press.

[23] Southend-on-Sea Borough Council and Mr Meyers [2019] EWHC 399 (Fam), [41].

[24] Belshaw, C. (2025) Assisted dying bill: why fears about coercion may be exaggerated – a philosopher's view', The Conversation, 22 January.

[25] Sterbeverfügungsgesetz (Death Directive Act) 2021. On the Austrian law, see Doppler, K. & Kleteka - Pulker, M. (2025) Assisted suicide in Austria', in White B.P. (ed.) Research Handbook on Voluntary Assisted Dying Law, Regulation and Practice. Cheltenham: Edward Elgar.

[26] Bundesministerium für Arbeit, Soziales, Gesundheit, Pflege und Konsumentenschutz (2025) End of Life Directive – Practical Guide. Bundesministerium für Arbeit, Soziales, Gesundheit, Pflege und Konsumentenschutz, p.6. Translation into English provided by Google Translate.

[27] Government of South Australia (2025)  Voluntary Assisted Dying Clinical Guideline for Health Practitioners', p.6.

[28] The Court of Protection of England and Wales has placed emphasis on whether the expressed views of

a person with intellectual and physical disabilities were their own, in the context of a relationship in which their mother's views and influence were pervasive, for instance: London Borough of Brent and NB, SA, AD, MB, SB [2017] EWCOP 34.

[29] Buchbinder M. & Berens N. (2024) Beyond coercion: reframing the influencing other in medically assisted death', Journal of Medical Ethics 50, pp. 841-845. Norwood's study in the Netherlands found that the large majority' of patients made their requests for an assisted death in the context of both familial and societal relationships'.  Norwood F. (2007) Nothing More to Do: Euthanasia, General Practice, and End-of-Life Discourse in the Netherlands' Medical Anthropology 26, pp.139-174, p.159.

[30] Chervenak, F.A., McCullough, L.B. & Skupski, D.W. (1993) An ethical justification for emergency, coerced caesarean delivery', Obstetrics & Gynecology, 82, pp. 1029–1035. See also Buchbinder and

Berens 2024: 842, ibid; Bell, A. (2007) Abuse of a Relationship: Undue Influence in English and French Law', European Review of Private Law, 15, pp. 555–599. p.564.

[31] See also Barlow C. & Walklate S. (2022) Coercive Control. Routledge, chapter 2.

[32] Buchbinder and Berens 2024: 843.  

[33] P.18/2024, [24.ii], p.23.

[34] For instance, the burden' perception has been raised repeatedly during parliamentary consideration of the Terminally Ill Adults (End of Life) Bill for England and Wales. The word burden' and closely associated words in this context appeared 140 times in the House of Commons Public Committee sittings alone. See Public Bill Committee Terminally Ill Adults (End of Life) Bill, PBC (Bill 012) 2024 – 2025. Concerns about the burden perception are not new. In Pretty v. DPP [2001] UKHL 61, [29], for example, Lord Bingham commented: [i]t is not hard to imagine that an elderly person, in the absence of any pressure, might opt

for a premature end to life if that were available, not from a desire to die or a willingness to stop living, but from a desire to stop being a burden to others'.

[35] Self-perceived burden' is the term coined by Cousineau, N., McDowell, I., Hotz, S. & Hébert, P. (2003) Measuring Chronic Patients' Feelings of Being a Burden to their Caregivers: Development and Preliminary Validation of a Scale', Medical Care, 41(1), pp. 110–118. The authors define self-perceived burden' as a multidimensional construct arising from the care-recipient's feelings of dependence and the resulting frustration and worry, which then may lead to negative feelings of guilt at being responsible for the caregiver's hardship.' (at p.111).  

[36] McPherson C.J. and others, Feeling like a burden to others: a systematic review focusing on the end of life' (2007) 21 Palliative Medicine 115-128. See also Ost and Biggs 2022: 168.

[37] Buchbinder and Berens 2024: 842.

[38] Oregon Health Authority (2024) Oregon Death with Dignity Act Data Summary, p.16.

[39] Variath, C., Peter, E., Cranley, L., Godkin, D. & Just, D. (2020) Relational influences on experiences with assisted dying: A scoping review', Nursing Ethics, 27(7), pp.1501–1516, p.1506.

[40] Variath et. al. 2020: 1506.

[41] Buchbinder and Berens 2024: 842.

[42] Saji A., Oishi, A. and Harding, R. (2020) Self-perceived Burden for People With Life-threatening Illness: A Qualitative Systematic Review' Journal of Pain and Symptom Management, 65(3), e207 - e217.

[43] Saji and others 2020: p.e207.  

[44] Rodríguez-Prat, A., Balaguer, A., Crespo, I., Monforte-Royo, C. (2019) Feeling like a burden to others and the wish to hasten death in patients with advanced illness: A systematic review' Bioethics, May;33(4), pp.411-420, p.411.

[45] We note the significance attached to autonomy in two of the individual submissions that are supportive of the legalisation of assisted dying, with Jeannine Hochet stating that Assisted Dying gives a person the chance to die at a time and date of their choosing, when all else has failed', and David Souville

emphasising the ability to choose to have a dignified death'.

[46] Ost and Biggs 2022: 91.  

[47] Ost and Biggs 2002: 182. It is true that many disabled people, by reason of a range of factors including poverty and social exclusion, find themselves in vulnerable situations. However, to call a person

vulnerable conflates their situation with their identity. This is problematic [because] it evokes a damaging misperception of disabled people as weak and in need of paternalistic protection ' Law Commission

(2013) Hate Crime: the Case for Extending the Existing Offences Consultation Paper No 231. HMSO, p.2.151. See also Collins J. (2015) A Study of Exploitation for the Criminal Law' (DPhil thesis, University of Oxford), p.159.

[48] Fineman 2014: 318.

[49] Formosa P. (2013) The Role of Vulnerability in Kantian Ethics' in Mackenzie C. and others (eds.), Vulnerability: New Essays in Ethics and Feminist Philosophy. Oxford University Press, pp. 88-109, p.106 (emphasis in original).

[50] Ost and Biggs 2022: chapters 4 and 6.

[51] Mullock, A. & Lewis , J. (2025) Assisted dying, vulnerability, and the potential value of prospective legal authorization', Medical Law Review, 33(2), fwaf014; Mackenzie, C., Rogers, W. & Dodds, S. (2014) What Is Vulnerability and Why Does It Matter for Moral Theory?' in Mackenzie, C., Rogers, W. & Dodds, S. (eds.), Vulnerability: New Essays in Ethics and Feminist Philosophy. Oxford University Press, pp. 1–29.

[52] It is worth noting that this characterisation of inherent vulnerability in assisted dying contexts does not extend to those with incurable somatic conditions or physical disabilities. Whereas the general concept of inherent vulnerability does extend to those with incurable somatic conditions and physical disabilities, being inherently vulnerable to assisted dying entails being vulnerable to making a genuinely autonomous decision on the question of accessing assisted dying. Having a somatic condition or a physical disability would not, in and of itself, affect one's capacity to make an autonomous assisted dying request. However, the autonomy of individuals with incurable somatic conditions or physical disabilities may still be at risk because such individuals may be at risk of undue external influence. As a result, they may be vulnerable to assisted dying, but the source of that vulnerability is situational rather than something directly caused by their intrinsic condition or disability. It follows that someone with a physical disability could be contingently vulnerable to assisted dying (i.e., because of the situational vulnerability that their disability could engender), whereas someone with a mental condition that rendered them mentally incapacitated would be necessarily vulnerable to assisted dying because they would be unable to satisfy the cognitive conditions for autonomy, and the source of that incapacity would be intrinsic to them.

[53] Lazin and Chandler have recognised the relevance of Mackenzie, Rogers and Dodd's work to assisted dying in their analysis of developments in Canada (see Lazin, S.J. & Chandler, J.A. (2023) Two Views of Vulnerability in the Evolution of Canada's Medical Assistance in Dying Law', Cambridge Quarterly of Healthcare Ethics, 32(1), pp.105–117). Mullock and Lewis develop this discussion in order to explore the vulnerability/autonomy dichotomy and the current prohibitive regime, as they manifest at law in England in Wales (Mullock and Lewis 2025).

[54] See Alignment between the draft law and adult safeguarding structures section below. Specifically, we are concerned about the intersection of coercive control, femicide, and assisted dying, particularly in situations where individuals experiencing illness, disability, health conditions or age that can render them susceptible to abuse. Standing Together Against Domestic Abuse (STADA), Evidence Submission to the Committee on the Assisted Dying Bill 11.2.25.

[55] Article 65(2)(c), P.65/2025. See further below.

[56] Hopkins, S.A., Price , A. & Etkind, S.N. (2025) Why we need to consider frailty in the assisted dying debate' Age and Ageing 54: afaf028, 3.

[57] Hopkins et al 2025: 2.  

[58] Person 1, Person 5 and Person 7, pp.77, 88 and 91, respectively.

[59] Jean is worried about being a burden' on her daughter, who has a young family and is already caring for Jean' (P.65/2025, p.77). There is no exploration of this issue beyond there being an additional social worker assessment (involving separate discussions with the individual and their family members) that considers family dynamics and rules out' coercion and the request not being voluntary. There may be a risk that this does not pay sufficient consideration to the way in which the burden self-perception might intersect with family dynamics – does the social worker's assessment suggest that the individual's burden self-perception is assuaged by her family, for example? The assessment that the individual's request is voluntary is repeated through each step in the process, but there is no consideration of whether the

burden self-perception is revisited at any point. It is good to see that case study seven (P.65/2025, pp.91 -

93) demonstrates that the social worker pays consideration to the complex family relationships and aspects of overly persuasive behaviour in their assessment demonstrated by the sons.' However, the social worker concludes (and is confident') that the person's decision is voluntary and his wish for assisted dying pre-dates any involvement from his sons.' (p.92). This case study raises the important issue of overly persuasive behaviour' and whilst the person's wish pre-dates the involvement from his sons, no information is provided about how the social worker decides that the person's decision post his sons' involvement is not being impacted on and encouraged by this overly persuasive behaviour.

[60] See Appendix 2 for examples of possible frameworks for identifying coercion and undue influence in the academic research.

[61] Article 65(2)(c), P.65/2025. Similarly, identifying and assessing risk factors for abuse or coercion' is a matter included in training that may be approved in legislation in Australian States (see Victoria's Voluntary Assisted Dying Act 2017, s.114(c); Western Australia's Voluntary Assisted Dying Act 2019, s.160(c)

[62] Article 88, P.65/2025.

[63] Addendum Report to P.65/2025, [57], p.28.

[64] Addendum Report to P.65/2025, [58], [59], p.28.

[65] Addendum Report to P.65/2025, [69.m.d.], p.32.  

[66] Addendum Report to P.65/2025, [69.m.d.], p.32. 71 Addendum Report to P.65/2025, [69.j.a.], p.31.  

[67] Addendum Report to P.65/2025, [97.a.ii.], p.42.

[68] Addendum Report to P.65/2025, [97.a.iii.], p.42.

[69] Addendum Report to P.65/2025, [97.a.iv.], p.42.  

[70] Addendum Report to P.65/2025, [97.b.ii.], p.43. What is set out in the Addendum here bears much similarity to what is set out in the guidelines in Victoria and Western Australia: State of Victoria, Department of Health and Human Services (2019) Voluntary assisted dying: Guidance for health practitioners, p.40; Department of Health, Government of Western Australia (2024) Western Australian Voluntary Assisted Dying Guidelines, [8.4] p.42.

[71] Addendum Report to P.65/2025, [97.b.iii.], p.43.

[72] Addendum Report to P.65/2025, [91.g.], p.38.  

[73] P.18/2024, [278-281], p.87.

[74] Addendum Report to P.65/2025, [58], [59], [61], pp.28-29.

[75] We thus wonder whether criticisms in an academic opinion piece that there is only limited coverage of coercion in the assisted dying training in Victoria, with the content related to spotting coercion estimated to amount to only five minutes' are only based on an assessment of what is publicly available, rather than what is in the actual training content available in the modules. See Donaldson, A., Neal, M. and Jones, D.A. (2025) Opinion: "Too difficult" or just too dangerous? The very real danger of coerced death under "assisted dying" laws', Scott ish Legal News, 11 June.

[76] Available at https://www.health.vic.gov.au/voluntary-assisted-dying/training-for-medical-practitioners  

[77] State of Victoria, Department of Health and Human Services (2019) Voluntary assisted dying: Guidance for health practitioners, p.40.

[78] Ibid.

[79] Ibid., p.41.

[80] We also note the view of the Jersey Care Commission that The ethical framework underpinning the Draft Law appears to strike a considered balance between respect for individual autonomy and the protection of life. The Commission is of the view that the principles of dignity, compassion, and non- coercion are appropriately embedded throughout the legislation.' Jersey Care Commission submission to the Assisted Dying Review Panel, 4.11.2025, p.2.

[81] Article 9(1)(d), P.65/2025. The exception to this is where the assessing doctors are both of the opinion that the individual is likely to die in less than 14 days from their first request, in which case, there is no minimum time period (Article 7(3)(d), P.65/2025).

[82] [64], P.65/2025, p.16.

[83] Appendix 5, [19], P.65/2025.

[84] Article 17(7)(d), P.65/2025.

[85] Under Victoria's Voluntary Assisted Dying Act 2017, the witness who signs a written declaration must confirm that, in the presence of the witness, the person making the declaration appeared to freely and voluntarily sign the declaration' (s.36(1)(a)(i)). Oregon's Death With Dignity Act requires that the patient's written request is witnessed by at least two individuals who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is capable, acting voluntarily, and is not being coerced to sign the request.' Chapter 127.815 §3.01. and 127.820 §3.02. The actual wording of the witness declaration form is that the person appears to be not under duress, fraud or undue influence' 127.897 §6.01.

[86] Article 17(7)(b) and (c), P.65/2025.

[87] Safeguarding Partnership Jersey: Arrangements to Safeguarding Adults at Risk of Serious Harm (2025).

[88] Under the Children and Young People (Jersey) law (2022).

[89] Safeguarding Partnership Jersey, ibid, pp.3-6.