Terminally Ill Adults (End of Life) Bill

Baroness Cass Excerpts

2nd reading
Friday 12th September 2025 Lords Chamber

[Baroness Cass (CB)]

My Lords, like others, I thank the many people on both sides of the debate who have written to me to share their views and deeply personal stories. For the sake of transparency, I will say that, on a personal level, I am supportive of the principle of assisted dying in very narrowly defined circumstances. However, I am deeply concerned about the Bill as it stands and do not consider it either safe or deliverable. I will focus on just one aspect.

As part of the consent process, the Bill requires three different doctors—the one undertaking the preliminary discussion, the co-ordinating doctor and the independent doctor—to discuss the primary diagnosis, prognosis and treatment options, as well as palliative care options, including symptom management. The latter two doctors must also assess for coercion, domestic abuse and capacity, as well as discussing the assisted dying process. I believe I am the most recently retired medic in this House, having given up my licence to practise last month.

Throughout my recent review, I devoted much time and discussions to thinking about meaningful informed consent. Back in the day when I was a junior houseman, we were expected to take consent without knowing much about the relevant procedure or how adequately to answer patients’ questions. We have come a long way since then. Options are explained to patients first-hand by clinicians who are specialists in the topic they are discussing, because it is impossible for other doctors to be up to date with a rapidly evolving range of treatments. You may assume that in the case of those seeking assisted dying, this has already been done by the treating doctor, but when someone imparts a serious diagnosis, you often blank out everything that is said thereafter and may be fearful of asking additional questions.

We know nothing about the background and qualifications of the three doctors who are expected to fill this potential gap. The latter two are at least supposed to be able to examine the patient’s medical records and speak to treating professionals, but written records are rarely adequate as a basis for such discussion and there are major complexities in doctors external to an organisation accessing electronic records. Furthermore, the treating doctor may not be available in a timely way. As for advising on palliative care options, the only professionals who can explain the full range of symptom-control measures are palliative care consultants.

In other words, the co-ordinating and independent doctors are being asked to take on two wholly different roles. The first is to substitute for a full multidisciplinary assessment involving the team managing the primary diagnosis, a palliative care specialist and, in some circumstances, a psychiatrist and a social worker. I submit that such an MDT assessment should be a core NHS function. It should identify the patient’s main concerns and fears and share information about possible options, ideally in a family context. This should happen up front, before discussions about an assisted death, rather than at the end of the process, when it is far too late to generate a trusting relationship.

The second role is the process of consenting to assisted dying, which should be considered separately once other options have been discussed and rejected. For the reasons that the noble Lord, Lord Lamont, gave, I believe that this should be through a service external to the NHS.

I have worked in MDTs throughout my career, and the key is respecting the unique skills of colleagues and listening to their views, so I have formed my views on this topic on the basis of not just my experience but, in large part, by listening to organisations representing key professionals: GPs, psychiatrists, palliative care consultants and physicians. I strongly encourage noble Lords to take their views very seriously in further deliberations, and for that reason I will be supporting the amendment from the noble Baroness, Lady Berger.

Terminally Ill Adults (End of Life) Bill

Baroness Cass Excerpts

Committee stage
Friday 14th November 2025 Lords Chamber

[Baroness Noakes (Con)]

My Lords, I am a little confused about this debate. The debate is on Amendment 2, which would replace “capacity” with “ability”, but we have heard hardly anything about ability. We have heard from the noble Lord, Lord Pannick, who said that it would replace a defined term with an undefined term, which is an issue we should take seriously, but most of the debate has been about whether the definition of “capacity” in this Bill—that in the Mental Capacity Act—is the right one to use. We are not debating whether “ability” is a better term; I hope that we can do that and move on to some other important areas in this Bill.

[Baroness Cass (CB)]

My Lords, I declare my interests as trustee of a children’s hospice. I also talk as a retired doctor with experience of looking after terminally ill adults and children. However, I also talk as somebody who is pretty familiar with conflict and polarisation, having been attacked and undermined on social media. I know that everyone in this Committee is committed to improving this Bill, and so I was somewhat dismayed by the article in the Times, which I felt led to the targeting, unfairly, of some of my noble friends who have been committed to improving this Bill and have been working hard to do so. I am not sure what the objective of that was, but it is regrettable.

People have asked about ability per se, so I talk now as a developmental paediatrician. We generally talk about abilities as skills that we acquire, whether it is a baby learning to walk or talk, or other skills that are more sophisticated. The skill that allows us to make reasoned judgment is the development of what is called the executive function—I am sure that noble Lords are all aware of that. That sits in the frontal lobe of our brains. As we well know, teenagers are pretty ill developed in that respect: they can talk with great authority about why it is extremely dangerous to drive too fast and break the speed limits and be very convincing on how they understand that and then, the next day, do exactly that, particularly under peer pressure. That judgment is something that develops but can also be lost, as we well understand, when somebody sustains a head injury or maybe has a brain metastasis that impacts that area, or during dementia; our judgment deteriorates.

The word “ability” allows us to think about people who might never develop that ability because of a problem in executive function, which is common in some people with autism. They may be well able to repeat what they have read online or heard from peers, but they have not fully understood and processed it. Some people with autism are of course well able to make those judgments and some are not: it is complicated, as my noble and learned friend pointed out, and there is perhaps an unwarranted confidence in doctors’ abilities to do that. It is very much a multidisciplinary team effort and one that requires somebody who knows the person well, or maybe multiple assessments. This is complex and “ability” encompasses a wider facet than capacity alone.

Terminally Ill Adults (End of Life) Bill

Baroness Cass Excerpts

Committee stage
Friday 21st November 2025 Lords Chamber

[Lord Shinkwin (Con)]

My Lords—

[Baroness Cass (CB)]

My Lords—

[Noble Lords]

Shinkwin!

--- Later in debate ---

[Lord Goddard of Stockport (LD)]

The noble Lord is on completely the other side of the argument, and I respect his views on that. This Bill has been scrutinised for over 100 hours in the other place. Evidence was taken from over 500 people. This is not just a piece of paper sent up here for us to determine.

[Baroness Cass (CB)]

Regardless of the amount of scrutiny, there are absolute conflicts between intent and delivery. The reason there cannot be trust in how we deliver this in real life is the very point made by the noble Baroness, Lady O’Loan, and the noble Lord, Lord Shinkwin: on the one hand, we are discussing the importance of coercion and of recognising it, yet it has been voted that you cannot ask the person why they want to die. I do not know how you can then possibly assess coercion. Unless you can hear from the person in their own words why they want an assisted death, you cannot even advise on symptom control, let alone on whether they have been coerced. There is the conflict between the intent on page one and what is expected in the delivery. If the Bill has arrived here with that level of conflict between what is on the first page and how it is expected to be delivered, then we change that; otherwise, it is not fit to pass through this House.

[Lord Goddard of Stockport (LD)]

I respectfully accept that position. The problem is that the more I speak, the more I will be intervened on, which is the opposite of what I am trying to do; I am trying to speed the process up.

All I am trying to say is that we all want the best Bill possible. I get that. If that cannot be managed, something else will have to happen. I was only trying to bring in the evidence of three former Directors of Public Prosecutions. One of them, because people had said, “We’ve had no real-life experience”, actually advanced to us, “I’ve got Parkinson’s disease and I’m going to die. I have a terminal illness”. He actually said that to the committee, and added that if the Bill passed he hoped to avail himself of it. That is just one little anecdote from probably the only person who gave evidence who actually has a condition, which he confirmed to us freely. He was not asked to do that.

All I am trying to do is balance the evidence, because a lot of people are quoting evidence. I want to try to redress that a bit and to gently move this on a bit quicker. I have completely failed, because I have been standing up for nine minutes. I apologise to the Committee for taking up too much time.

Terminally Ill Adults (End of Life) Bill

Baroness Cass Excerpts

Committee stage
Friday 5th December 2025 Lords Chamber

[Baroness Cass (CB)]

My Lords, as Sarah-Jayne Blakemore has been widely referred to, it might be useful to directly quote her. She said:

“Most of these age cutoffs have not been based on what we know about brain development, because they were decided way before we knew anything about how the brain develops during adolescence. So what I would say is that those kinds of decisions about age cutoffs”—


she is referring to the various age cut-offs for drinking, marriage and so on—

“should incorporate the new knowledge about brain development during adolescence. On the other hand, this is a question I’m asked often, I don’t think the neuroscience can provide an age for you. We can’t say, ‘Oh, the neuroscience shows that the brain becomes adult at age 18 or 24’ or whatever it might be. It’s much more complex than that”.

She goes on to describe how different brain regions develop and mature at different rates, and to talk about the individual differences in the speed of brain development:

“So what I would say is that what we know from neuroscience is the kind of age range, the very broad age range when the brain becomes mature and adult. And that’s much later than 18, between 20s and 30s for most people. So of course that cannot generate an age at which you become legally adult”.

That is what Sarah-Jayne Blakemore has said. On that basis, I support the suggestion from the noble Baroness, Lady Finlay, that, between the ages of 18 and 25, there should be enhanced and careful assessment, taking account of that perspective.

[Lord Falconer of Thoroton (Lab)]

I apologise for interrupting at this stage. This has been a very good debate, and it might be helpful if I indicate what my position in relation to this is. The thinking behind 18 is that that is the age at which you can make your own decisions about medical care. If you are suffering from a terminal illness, you can decide at 18 whether you want to withdraw treatment, for example, or what the treatment should be.

In answer to the noble Baroness, Lady Berridge, we were aware of the different views about when your brain and maturity develop, and what the noble Baroness, Lady Cass, said is absolutely correct—she read Sarah-Jayne Blakemore’s view—in that these age cut-offs that the law imposes generally are not based upon a close study of neurology; they are the law’s attempt to reflect maturity. I am indeed very aware of the fact that if you are 18, you may be more emotionally impulsive and more easily influenced than somebody of 25, 24 or 23. Equally, anybody who has had contact with people who are young and terminally ill will have found that some 18 year-olds are incredibly thoughtful and mature and some are not, for obvious reasons.

I am very influenced by the fact that I have been listening to people expressing real concern about this issue in this House. I still think 18 is probably the right age, but I am very influenced by what the noble Baronesses, Lady Finlay and Lady Cass, have said: that maybe the answer is some assurance that there is a more intense assessment for people aged between 18 and 25. The Bill says that you can have an assisted death only if you have

“a clear, settled and informed wish to end”

your life, and it is being done voluntarily. How can we be sure about those aged between 18 and 25? Two doctors and a panel have to make the decision, but some additional thing might be required.

We are slightly going around in circles again and repeating ourselves, so I suggest that I talk in particular to the noble Baronesses, Lady Cass and Lady Finlay, and that we come back on Report and see whether we need a more thorough assessment for people aged between 18 and 25—although I am not saying I am going to change the age of 18. That is broadly my position.