Why we need to consider frailty in the assisted dying debate

Background Assisted dying/assisted suicide (AD/AS) is legal or decriminalised in several countries and Bills to legalise it are currently being considered by the UK and Scottish Parliaments. Older adults living with frailty make up an increasing proportion of those who die, yet the possible implications of AD/AS for these individuals are relatively unexplored. Here, we discuss some of these issues. Discussion Frailty complicates AD/AS in relation to eligibility because of ambiguity over whether frailty constitutes a terminal illness, challenges in accurately predicting prognosis, and difficulty determining reversibility of suffering. Frailty also blurs the distinction between terminal illness and disability, in contrast to the clear-cut language of current proposed legislation where those with a terminal illness are eligible, but those with disability are not. We discuss that decisions regarding AD/AS are often framed in terms of individual autonomy, whereas relational autonomy is the norm for many living with frailty, meaning that concerns regarding implicit coercion need careful consideration. Further, there is an established link between frailty and feeling a burden to others. There is an open question as to whether this, combined with persisting ageist attitudes in society, could influence decisions of people living with frailty about an assisted death. Conclusion The above issues make the place of frailty in proposed legislation on AD/AS uncertain. Further consideration is needed regarding eligibility, safeguards in the context of relational autonomy and for those who already feel a burden, and how to mitigate risks of further entrenching ableist and ageist attitudes.