The Terminally Ill Adults (End of Life) Bill, currently before the House of Lords, has been presented by its supporters as a measure rooted in autonomy, dignity and choice. The framing is powerful. Who could be against those values?
But beneath the surface of the language lies another story — about the way we are subtly guided, pushed and pulled toward certain decisions by structures, systems and the very design of our choices. These are what behavioural scientists call nudges. Nudges are not supposed to be coercive — they do not forbid options or impose punishments. They are, as Richard Thaler and Cass Sunstein put it in their book Nudge, “any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.”
Nudges work precisely because they are not obvious. They operate below the level of consciousness. They are subtle, otherwise they wouldn’t work. In other words people can’t avoid the influence of nudges, because nudges are not visible or obvious in all cases. They work below the level of consciousness, they are subtle, otherwise they wouldn’t work. It is a contradiction that something can both influence choice and preserve freedom of choice.
Choice architecture can involve defaults, framing, timing, ordering, reminders, messenger effects or even small changes in the environment.
Nudges are now commonplace tactics in business, education, government and all walks of life. And in healthcare, nudges abound.
Nudges in healthcare
Some nudges are uncontroversial. In hospitals, hand sanitiser dispensers are placed near doors and corridors, accompanied by posters reminding staff to clean their hands. This simple change increases compliance. In prescribing, NHS systems sometimes display the cost of drugs alongside cheaper equivalents, nudging doctors toward more cost-effective options without banning alternatives. In vaccinations, pre-booked appointments and reminder text messages nudge uptake upwards.
Nudges have also been trialled specifically in end-of-life care. Studies show that default options on advance directives — whether life-sustaining treatment is the default or not — significantly shape patient choices. One US study found that when the default was set to comfort-focused care, more patients chose it than when the default was life-sustaining interventions. These are not trivial matters; they affect whether someone ends up in intensive care or at home with hospice support.
Reports on behavioural insights in the NHS have documented nudges in appointment scheduling, referrals, medication adherence and end-of-life planning. At first glance, nudges seem benign — what’s wrong with designing decisions so that people are more likely to wash their hands, take their medicine or keep their appointment? Yet when they are introduced into life-and-death contexts, particularly at the end of life, the ethical ground definitely becomes less steady. As one doctor explained:
“Clinicians appropriately wonder if something unethical is going on here. If nudges influence choice, how can we justify it? Traditionally, nudges have been justified when they help promote the things people actually want deep down. But as we’ve discussed, in the end-of-life space, it’s hard for patients to know what exact types of medical care will best help them achieve their goals. In such cases, clinicians should rely on a standard that they have historically relied on anyway: the ‘best interests’ standard, where, absent compelling evidence about what a patient would truly want, we should act in a way that we believe — or know, based on evidence — would promote their best interests.”
Reflecting on their own practice, they described how even seemingly neutral conversations about end-of-life decisions carry hidden nudges:
“As med students, we are all taught it is important to have conversations about whether patients wanted a DNR (do not resuscitate) order. We’re told that the way to do that is to be neutral – to say something like, ‘In this situation, your loved one’s heart might stop. If so, would he want us to do chest compressions?’ But that places an incredible burden on family members to feel like they have to know exactly what their loved one would want in this specific situation — something they rarely know with confidence. And in fact this isn’t all that neutral anyway — to say no to chest compressions requires giving up something, which is always hard to do.
That strikes me as problematic in cases where chest compressions would almost certainly do more harm than good. So as I developed more experience, I became comfortable saying, ‘In this situation your loved one’s heart may stop. If it did, we would not routinely do chest compressions, because they would be unlikely to work. Does this seem reasonable?’ This way, I’ve set a default option, but I’ve not removed any options. I’ve now used this language several hundred times with the families of patients who were most certainly going to die, and only once has a family chosen CPR. Indeed, several families have thanked me for helping them understand what the norms are.”
This recognition — that nudges are already being used in healthcare, and even in end-of-life care — should give us pause when we consider what it would mean to legalise assisted suicide within the NHS.
Nudges during Covid-19
The Covid-19 vaccine rollout offers striking examples, which I wrote about at length in A State of Fear and Free Your Mind and numerous articles. I don’t want to repeat myself. But in essence it would fair to conclude that the vaccine was promoted with a unique panoply of nudges, before eventually being foisted upon the remaining unwilling unvaccinated population with mandates, varying country by country.
Whether one applauds or condemns specific interventions, the route in recent years has been the same. In the case of governments, nudges sometimes appear to be merely the first tool deployed in pursuit of a policy goal, which may continue upon an exorable path of nudges, shoves and pushes, finally culminating in cattle prods.
The comparison between vaccines and assisted suicide is not niche. The nudges used for one and potentially for the other raise urgent questions of bodily autonomy and the dangers of the state blurring the line between influence and coercion.
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The conflict within the NHS
The NHS is charged with preserving life, promoting health, preventing suicide and relieving suffering. To ask the same institution to also provide assisted suicide is to create a profound conflict. On one hand, the NHS works daily to prevent suicide in people with mental illness, poverty or social isolation. On the other, it would be offering suicide assistance to people who meet the Bill’s criteria. The distinction may be clear in law, but in practice it is fragile.
More fundamentally, the NHS would find itself choosing between life and death as treatments. Life-extending care, palliative interventions and hospital stays are expensive. Assisted suicide, once established, is relatively inexpensive compared to palliative care.
The government’s impact assessment of the Assisted Dying Bill is candid about cost and savings. The projected “savings” to the NHS once it offers “assisted deaths” are up to £59.6 million per year by the tenth year, due to what the assessment calls “unutilised healthcare”. That is, care not provided because patients died earlier through assisted suicide.
The impact assessment explicitly presents assisted dying as a cheaper option. And there will be further savings in welfare and pension bills.
Once the system internalises this logic, the nudge becomes clear: over time, patients may be steered — subtly, even unconsciously — toward the cheaper, system-saving choice.
Quite simply, assisted suicide is more cost-effective for the tax payer.
The debate as a nudge
It is not only in clinical encounters that nudges will operate. The political and cultural debate itself has been structured through nudges. By framing the Bill in terms of “autonomy” and “choice”, its proponents shape public perception before ethical dilemmas are confronted. And by presenting financial savings, the impact assessment reframes death as efficiency. These are nudges of rhetoric and policy.
Disability rights groups have been vocal in opposing the Bill. Disability Rights UK said: “Assist us to live before you assist us to die.” Their concern is that vulnerable people — disabled, elderly, socially isolated — will internalise a sense of being a burden, a subtle nudge toward choosing death.
Former Prime Minister Theresa May described the Bill as a “licence to kill” that risks creating pressure on people to end their lives. The British Medical Association has recommended that if assisted dying becomes law, it should be arranged through a separate service, with no duty on doctors to raise the option with patients — an attempt to minimise the normalisation that would otherwise nudge patients toward it.
The central paradox is this: the Assisted Dying Bill is presented as enhancing autonomy, yet the very structures it creates may (surely will) channel people’s choices, not just through nudges but due to inequality in palliative care choices across the country.
In other countries, eligibility criteria have expanded and uptake has grown beyond original projections. Belgium, the Netherlands and Canada all show how normalisation changes the choice architecture over time.
Autonomy is not exercised in a vacuum. It is exercised within systems, under resource constraints and amid cultural expectations. Patients do not walk into neutral rooms where all options sit equally on the table. They arrive at consultations tired, afraid, sometimes in pain, often anxious, perhaps misinformed and quite possibly unable to access high quality palliative care due to resource constraints. They are met by doctors working in overstretched institutions, who themselves are subject to nudges, pressures and policy targets. In such a setting, the line between offering a choice and steering towards one can become thin to the point of invisibility.
This is why nudges matter so much here. They are used to shape organ donation, vaccine uptake, screening programmes, and even end-of-life care through defaults in DNR discussions. They are subtle, often invisible, and they work. To imagine that assisted dying would sit outside this pattern is naive. The NHS would be tasked with providing both life and death. When cost pressures bite — and they always do — which option will be the easier sell? Which leaflet will be in larger print? Which button online will be bigger? Which choice will be accompanied by the most flattering language? Which option will be endorsed by celebrities? Which path will feel more aligned with the “responsible” choice? Which will be more convenient and easier? The nudge will be there, and it will rarely be recognised for what it is.
Supporters of assisted dying say it is about compassion and autonomy. But compassion is not neutral when death is cheaper than life, and autonomy is never absolute when architecture shapes choice. To legislate for assisted dying is to legislate for a new form of state power over death — not by force, but by suggestion, by framing, by defaults — by nudging. And once such an architecture is built, it will not be easily dismantled.
The debate should not only be about whether assisted dying is compassionate or cruel, but about how choice itself is constructed, and who benefits when death becomes an option offered by the very system meant to preserve life. Because when the nudge comes — and it will — it will not look like coercion. It will look like choice and freedom. And that is precisely what makes it so dangerous.
Nudged into a mass grave with a bulldozer.
All of that is true. And that alone is sufficient grounds to reject state-sanctioned murder "for their own good" wrapped on benign terms like "assisted suicide" or "euthanasia." The "nudges" and perverse incentives you explain are not a benign architecture of choice.
But that architecture you describe, that Sunstein and Thaler described, doesn't use just a stool to construct. It uses a "ladder." And on a ladder there is more than one step. Each rung on the ladder goes higher and higher into the world of coercion until the top rung of mandates is reached. And "assisted suicide" is ordered, the standard protocol becomes state-sanctioned murder of "undesirables," "useless eater" drains on resources. The 'compassionate' thing that 'good' people do.
This is how it inevitably escalates once the decision is made to step onto the choice architecture ladder. The first rung being the just that - the first.
We saw this during plandemic, voluntary mask guidance became mandatory, free faces violently assaulted by police, merchants, Karen's and Ken's. Voluntary injections of experimental biotech became mandatory to exist, work, eat, play.
And the world saw the choice architecture of "euthanasia" become mass murder crimes against humanity in just a few decades after stepping on the first rung of the ladder a century ago. By people no worse than we are today, albeit without the fancy academic lingo of "nudge" and "choice architecture" behavioural science" being employed.
It's just where it goes. No grand scheme or design, no conspiracy necessary. Just human nature and how incentives, groupthink and moral busybodies convinced of their system of ethics, utilitarianism, calls for the "greater good" sacrifices of the few for the many.
There is no possible way to build in protections from past abuses, murderous public policy in practice if not law, that will withstand all who hold that power. The power of that ring so intoxicating that it cannot be put down, "my precious."
As the BIT nudgers Laura interviewed in State of Fear described how their best intentions led to authorities drunk on power making the newly reticent fearful of the future of our free, democratic society.
"Assisted suicide" is given a ladder of interventions when it becomes state policy, not a stool many well-intentioned caregivers imagine when they step on the first rung of "nudges."
The sanctity of life must be preserved, no matter how heartbreaking individual stories are. For the greater good of not unleashing mass murder crimes against humanity...again. Aren't we supposed to learn from history lest we be doomed to repeat it?