Terminally Ill Adults (End of Life) Bill

Debate between Baroness Hollins and Baroness O'Loan

Committee stage
Friday 20th March 2026 Lords Chamber

[Baroness O’Loan (CB)]

I have put my name to Amendments 300, 538 to 540, 541 to 543 and 544B in this group because of the importance of independent advocates and the definition of who they may—or should—be made available to. As has already been alluded to, the fact that the Bill provides for somebody with a disability is compounded by the fact that people with a learning disability in particular can want to please those whom they perceive to be in authority over or looking after them. They can think that people will act in their best interests, and they will very often comply with what is proposed to them. That is one of the things that make this issue profoundly important. What is so lacking in Clause 22 is the specificity that would enable one to articulate what an independent advocate is. In a minute, I will come to the amendments proposing a new Clause 22.

Amendment 300, tabled by the noble Baroness, Lady Grey-Thompson, proposes a new clause requiring the appointment of special independent advocates for disabled people as defined by the Equality Act. That is a wider definition of those for whom independent advocates should be provided. However, it recognises that, in those moments of considering a choice between life and death, a person needs to be cared for, so that the stresses that they will inevitably experience do not prevent them making an informed decision under the Bill. It is very important for such advocates to be trained specifically in disability rights and the identification of coercion. Amendment 300 is specific in identifying the range of support and advice that must be made available. Amendment 539 similarly requires specific communication training, which is essential for someone to act for a person with a profound disability, as we heard in an earlier group today.

Amendment 541 in the name of the noble Lord, Lord Sandhurst, specifies conflicts of interest that would preclude someone from acting as an independent advocate, and I agree that it is important that these be spelled out in the Bill.

Amendment 542 states what the independent advocate cannot do. In particular, they should not be there to support a person to have capacity to end their own life; nor should they advocate for someone, as under the MCA arrangements. Rather, they should ensure that the person seeking to end their own life understands what is being offered to them and understands the consequences of complying with the suggestions, thereby enabling them to respond to the options made available to them.

Amendment 548 seeks to amend Clause 22(4)(b) by making more specific the difficulties that may be faced by a qualifying person.

In responding to the DPRRC report, the noble and learned Lord, Lord Falconer, has tabled the amendments to which he has already spoken. However, I have concerns. The changes proposed by the noble and learned Lord no longer provide an obligation on persons performing functions under the Act to ensure the presence of an independent advocate for a qualifying person. Subsection (9) of the proposed new clause in Amendment 548A says that someone

“‘has’ an independent advocate if an independent advocate is instructed to represent and support them”—

it is not that they need to be present or involved; they merely have to be instructed.

At this point, it is important to remember why the independent advocate is there in the first place: to provide support to someone who has difficulty understanding and who may very quickly forget, after the conversation, anything that has been said to them. That is why the independent advocate must be present. Can the noble and learned Lord tell us why he removed that requirement? Does he think that an independent advocate could support someone if they are not present for the discussions and consultations?

More chillingly, subsection (3)(c) of the proposed new clause in Amendment 548A says that a “preliminary discussion” can proceed even where

“the person seeking assistance informs the relevant person that they are content for the preliminary discussion to be conducted without them having an independent advocate”.

It is not difficult to imagine a situation in which a registered medical practitioner asks, “Are you happy to go ahead without an independent advocate?”, and the qualifying person, possibly wanting not to annoy or even to please, says yes—and so the preliminary discussion goes ahead.

Subsection (3)(b) of the proposed new clause provides that the disabled person can say that they do not want an advocate, but how can we be sure that the person understands what an independent advocate is—we are having quite a discussion ourselves this afternoon about that—and what they might bring to them? Is it possible that a tendency towards needing privacy, and perhaps a tendency to not engage with strangers, might lead someone in this situation to decline an independent advocate without really knowing what they are doing? It would be helpful if the noble and learned Lord could explain how he intends to prevent this happening or to safeguard the person.

It would, of course, save quite a lot of money if the IA were declined. The noble Baroness, Lady Grey-Thompson, has referred to the £2,333 per case. I have a notion that it might be more, because some of these assisted dying cases are going to take quite a long time as they go through all the processes, particularly the process in the house, the hospital or wherever it is that the lethal drugs are to be administered. Assisted dying could take some time. If a disabled person says they do not want an independent advocate, things could move more quickly. There is significant risk here and the noble and learned Lord needs to help us understand the safeguards.

Subsection (8) of the proposed new clause provides a really important definition of an independent advocate, by saying that it is someone who represents and supports a qualifying person

“in connection with … anything done under this Act, by or in relation to the qualifying person”.

My questions for the noble and learned Lord are: what support is envisaged here and what is meant by that phrase? What support is the independent advocate going to provide when the doctor is providing the lethal drug under Clause 25(8)(b)? Is it assisting the person to ingest or otherwise self-administer the lethal drug? What is “support” in this context and that place? Is it possible that the person seeking to die might expect their independent advocate to hold the cup for them or press the syringe with them? Is the clause clear that support cannot include any active role? That would be vital.

Surely this could open the door to an interpretation by those who perhaps have malign intent—I am thinking about coercion here—that the independent advocate can do more than listen, explain and communicate. I wonder what is meant by Clause 25(8)(b) in any event. How far can the doctor go in helping the

“person to ingest or otherwise self-administer”

a lethal drug? We will get to that later, but what does it actually mean?

There is a massive difference between helping with communication and support and being present when someone takes lethal drugs to end their own life, or is assisted to do so by a doctor, and supporting that process. Amendment 549A does not add the kind of clarity required, but it does allow the independent advocate to access the person’s medical records or require information from those records. That seems to suggest that this independent advocate would require some kind of medical expertise, which has not been previously suggested. I do not know what the actual purpose of subsection (3)(d) of the proposed new clause in Amendment 549A is. It would be helpful if the noble and learned Lord could explain it to me.

There is a massive danger inherent in the terribly loose drafting of both Clause 22 and the noble and learned Lord’s proposed new clause in Amendment 548A, and some of the additional material contained in Amendment 549A. Can the noble and learned Lord explain why he has drafted an amended clause which seems even more deficient than the original Clause 22? Needless to say, I also support Amendment 549C, in the name of the noble Baroness, Lady Coffey, which would apply if Amendment 549A were passed.

[Baroness Hollins (CB)]

My Lords, as the noble Baroness, Lady Browning, is not in her place, she has asked me to introduce her Amendment 538, to which I added my name. It simply says that it would require the Secretary of State to consult

“disability rights organisations and the Equality and Human Rights Commission”

before making regulations.

The Bill is noticeably silent on the actual elements of the role of the independent advocate and allows the Secretary of State to detail what they should do—or not, as the case may be. This feels like a bit of a gap. Several disability organisations have raised real concerns about the Bill and have complained about a lack of meaningful engagement, despite their probably being most at risk if things did not work out quite as the noble and learned Lord the sponsor hoped. This is why they should be consulted when regulations are made; it makes sense.

Terminally Ill Adults (End of Life) Bill

Debate between Baroness Hollins and Baroness O'Loan

Committee stage
Friday 13th March 2026 Lords Chamber

[Baroness O'Loan (CB)]

It has not changed on the Government’s contemporaneous website. If I go to New Zealand, it says that the doctor cannot advise or discuss assisted dying with you unless you ask for it first. Those are both government websites today. I accept that there may be changes due and that they may come, but they are not there, as far as I can see.

[Baroness Hollins (CB)]

My Lords, when a doctor, the very person entrusted to preserve life and relieve suffering, raises the possibility of assisted dying, it is no longer a neutral act. For some people, particularly those who are depressed, isolated or overwhelmed, the mere introduction of the possibility of an assisted death risks planting the idea that this course is rational or even expected. In an inherently unequal doctor-patient relationship, suggestion is easily perceived as a recommendation.

There is no requirement for an independent advocate—somebody to sit beside the patient and help them process and grasp what is being said. We are leaving some of the most consequential conversations a person can ever have to take place in isolation, within an asymmetrical, authoritarian relationship. There is no requirement for the discussion to take place with someone with specialist expertise. A “registered medical practitioner” could be a locum doctor who the patient has never met before, a foundation-year doctor in their early years of practice, or someone with no training in palliative care or experience of autism or learning disabilities, and yet they are the people who may introduce a conversation that could seriously alter the trajectory of a life.

No clinician should be allowed to initiate such a conversation; it should arise only if a patient independently raises it themselves, and even then the doctor’s role should be limited to acknowledging the request and directing the patient to an independent body while remaining firmly focused on diagnosis, treatment and the provision of appropriate and timely palliative care, as needed. Assisted dying must not be presented as an equivalent option alongside treatment, support and comfort. To do so risks the medical service being seen as one that no longer values preserving and improving life but rather one that enables the end of life.

The Royal College of GPs has stated that the role of a GP should be limited to signposting patients to a designated specialist service if, and only if, the patient raises the subject. This week, the Royal College of Psychiatrists wrote to me expressing its continuing concern. Its view is that

“all applicants should receive a holistic, multidisciplinary assessment at the preliminary discussion stage, including for mental health needs”;

in other words, something much more like the multidisciplinary panel proposed by my noble friend Lady Finlay in the previous group. I therefore suggest that Clause 5, and, in consequence, Clause 6, should not stand part of the Bill.

Terminally Ill Adults (End of Life) Bill

Debate between Baroness Hollins and Baroness O'Loan

Committee stage
Friday 6th February 2026 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I added my name to Amendment 87, which details the exclusion of those with diagnosed eating disorders from accessing assisted dying, because I consider this a tricky area deserving of very careful debate. There are serious and specific risks that the Bill poses to people with anorexia nervosa and other eating disorders—conditions with the highest mortality rate of any psychiatric illness, but which are not terminal illnesses. They are complex fluctuating disorders, characterised by impaired insight and a distorted relationship with food, weight and how people view themselves.

Written and oral briefings that we have received make it clear that this is not just a theoretical concern. The Complex Life and Death Decisions group briefing on eating disorders documented how, in jurisdictions with assisted dying laws, eating disorders have been redefined as terminal once patients stop eating and drinking. This is despite the availability of effective evidence-based treatments and well-documented cases of recovery, even after decades of illness. A systematic review published last year in Frontiers in Psychiatry identified at least 60 individuals with eating disorders who died by assisted death in Oregon, Colorado and California—jurisdictions where, as in this Bill, assisted dying is restricted to terminal conditions. A third of those who died were in their teens or 20s, and all were women.

Cases such as this demonstrate the danger of conflating treatment refusal with terminal illness, and of mistaking the voice of a life-threatening psychiatric disorder for a wish to die. Starvation affects the brain in profound ways, including causing rigidity of thinking and allowing the illness itself to dominate choices. This can happen even to the point where perceived thinness is valued over life.

Yet people with anorexia can appear highly articulate and lucid, which can mask these deeper impairments and make capacity assessments unreliable. Many are judged to have capacity in other areas of life even while their decision-making around food, weight and choosing self-preservation is seriously distorted by the disorder. Someone may seem capable of making an end-of-life decision while simultaneously lacking capacity for the very decisions that would keep them alive. We need to acknowledge this complexity and proceed with the utmost care, recognising that these individuals are among those most at risk under the Bill.

Those who refuse to eat or drink because of mental illness must also be excluded from the Bill’s scope so that we can properly safeguard them and ensure that they receive the treatment and support that they need to recover. Amendment 87A would offer a valuable clarification, ensuring that this would apply regardless of whether the refusal of food or drink is voluntary or arises from a mental disorder. This would prevent any ambiguity that could otherwise allow conditions such as catatonia or other serious mental illnesses to be misclassified as terminal under the Bill. It would provide further safeguards for people with mental disorders.

There are mental-health conditions where life-threatening physical complications can occur without the restriction of food and drink. Amendments 90, 92 and 103 also cover this key area and would ensure that assisted dying is limited to people who are genuinely terminally ill due to disease progression and not because they choose to refuse care, food, fluids or treatment. A person cannot be considered terminally ill if their life-threatening condition arises from the secondary effects of mental illness.

[Baroness O’Loan (CB)]

My Lords, the issues raised in this group are extensive and a matter for great concern. Refusing food and hydration is a sure way to die, as, in many cases, is refusing treatment such as dialysis and insulin. Refusing food or treatment is a choice that a patient is entitled to make, if they have the capacity to make such a decision. However, that cannot translate into an obligation on the state to help the person to kill themselves. That was recognised, as the noble and learned Lord, Lord Falconer, said, by the Bill’s sponsor in the other place, hence the wording of Clause 2(2). However, the noble and learned Lord’s Amendment 87 would remove the safeguard offered by Clause 2(2), as it would prevent the Bill applying only where the person has a mental disorder and the act of refusing food or hydration causes them to have an illness or disease.

Many states start by offering assistance to die in very limited circumstances, but, only a short time afterwards, the grounds for the state helping people to kill themselves expand—in some cases, almost inconceivably. Do you have no wheelchair? We will help you die. Do you have no home? We will help you die. Are you suffering from PTSD after military service? We will help you die. In many jurisdictions, anorexia, which is a treatable illness, is accepted as justification for assisted suicide and so on. All the examples that I have just given—no wheelchair, no home and suffering PTSD—were grounds for assisted dying in Canada recently.

There are many suggestions for how to address the terrible vacuum through which all sorts of conditions that are not terminal could, as a consequence of refusing food, treatment or hydration, become terminal. I put my name to one such amendment, Amendment 101, in the name of the noble Baroness, Lady Parminter, and all the amendments in this group, other than Amendment 87, seek to address the issue. However, it is clear that the list of conditions and situations currently provided in Clause 2 as exceptions to the definition of terminal illness is not adequate. The noble and learned Lord, Lord Falconer, has even removed from the Bill the more general safeguard inserted by the MP for Batley and Spen. The noble and learned Lord will have to move far beyond his Amendments 87 and 87A if he is to satisfy the Committee that the definition of the situations that do not qualify as terminal illness is in any way satisfactory.

The prevalence of eating disorders goes way beyond what one might perhaps reasonably expect. NHS statistics for 2023 tell us that the prevalence of any eating disorder in the age group of 11 to 16 year-olds was 2.6%, but that in the case of girls it was 4.3%, compared with only 1% in the case of boys. If we move to the group of 17 to 19 year-olds, the figure is 12.5% in the whole group but, among girls, the number suffering from an eating disorder rises to 20.8%, compared with 5.1% among boys. Those are NHS figures. A review of current literature up to 2022 investigating suicide in eating disorders found that the prevalence of suicidal ideation was 51% and the prevalence of suicide attempts was 22%. I am very grateful to the young intern doing a PhD who provided me with these figures from the NHS. They demonstrate the magnitude of the problem of eating disorders today and, even more terribly, the 51% prevalence of suicidal ideation. Half of all people suffering from anorexia or other eating disorders will contemplate suicide, and more than one in five of those suffering from an eating disorder will attempt to take their own lives, although the disorder that they suffer from can be treated if they get proper treatment.

The Bill effectively creates a class of people—particularly disabled people, diabetics, those on dialysis, and others who need continuous life-sustaining treatment—who can at will cause themselves to have a terminal illness as defined by the Bill. Experts and the courts have agreed that refusing such treatment and creating a terminal illness out of a desire to die does not vitiate capacity. Can the noble and learned Lord, Lord Falconer, explain how creating a class of disabled people for whom voluntary suicide is legal and state-supported is consistent with the UK’s obligations under Articles 2 and 14 of the European convention?

Terminally Ill Adults (End of Life) Bill

Debate between Baroness Hollins and Baroness O'Loan

Committee stage
Friday 12th December 2025 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I would like to comment on this group in response to what the noble and learned Lord, Lord Falconer, has just said.

In its recent briefing for Peers, the Royal College of Psychiatrists gave its view:

“Assessors should be required to take all practicable steps to work with professionals involved in a person’s health and social care, and to talk to a relative, carer or nominated friend, including by accessing medical notes from both primary and secondary care”.


It expressed concern that

“a consideration of suicide protection duties are being bypassed by the Bill in its current form”

due to unmet need not being formally assessed. A previous DoLS is relevant to consideration of current capacity to decide to end one’s life. What would be the mechanism for reliably ensuring information that there has been a DoLS before it gets to the assessors and the panel?

Having mentioned the Royal College of Psychiatrists, I would like to make a short statement. The college has asked me to respond to the allegations about its leadership made by the noble Baroness, Lady Murphy, on 14 November, our first day in Committee. The president of the college, Dr Lade Smith, wrote to the noble Baroness asking her to withdraw her allegations, as they are inaccurate. But although the noble Baroness was present in the Chamber the following week, no clarification was provided. As a past president myself, I beg leave to set the record straight.

The college’s recommendations on the Bill are, in fact, based on 18 months’ consideration by a cross-college working group involving membership surveys, debate with members on proposals before other jurisdictions, and discussions with colleagues in other jurisdictions where assisted dying is practised. The president is clear that Dr Annabel Price, the appointed college lead for the Bill, has accurately represented its views when giving formal evidence to both Houses. With the Bill before the Lords, the Royal College of Psychiatrists is focusing on how to make it safer for people with mental health needs and learning disability needs, and better aligned with the responsibilities of psychiatrists. I feel that, in the light of the discussion on DoLS, this is an appropriate statement to make.

[Baroness O’Loan (CB)]

My Lords, I have put my name to Amendment 16. I also support Amendments 16A, 114 and 114A because the very general definition in Clause 1 of a terminally ill adult who has the capacity to take their own life does not contain any consideration of those who have been deprived of their liberty under Section 4 of the Mental Capacity Act. It is an unfortunate reality that many of those detained in hospitals or care homes are detained because they lack the capacity to make a decision about their own care or treatment. As the noble Baroness, Lady Finlay, said, in such circumstances it is surely axiomatic that there should be careful consideration of cases involving individuals subject to a DoLS.

As the noble and learned Lord, Lord Falconer, said, even assessing the capacity of someone with dementia or another neurological condition, for example, can be profoundly difficult. This is not just because of the frequent fluctuation of both capacity and the extent to which any identified capacity enables the making of a particular decision; a medical practitioner or social worker who meets a person for the first time may be misled as to the capacity they actually have. As the Royal College of Psychiatrists noted in its written evidence,

“an assessment of a person’s mental capacity to decide to end their own life is an entirely different and more complex determination requiring a higher level of understanding”

than in other assessments of capacity.

In the 1997 case of Re MB, the noble and learned Baroness, Lady Butler-Sloss, said:

“The graver the consequences of the decision, the commensurately greater the level of competence required to take the decision”.


Capacity assessment is not a precise science. The unique context of this Bill makes taking a cautious approach appropriate. It is common sense that there is a likely correlation between incapacity in one area, so extreme that the state must deprive the person of their liberty, and incapacity to decide whether to end one’s own life. People whose incapacity for basic decisions is so severe that they are deprived of their liberty are the most vulnerable members of society.

I want to give your Lordships a brief example. I was aware of a woman in her late 80s who had been assessed and was subject to a DoLS. She objected to it and appealed against it. Intellectually, she was enormously able, possessed of considerable social skills despite her dementia. She was able to persuade those dealing with her appeal that she had capacity despite the very real concerns of her family, who knew the extent of her incapacity. The DoLS was lifted and she went back to her own home. Shortly afterwards, she was found playing golf in the road in her pyjamas at two o’clock in the morning. She was going to the supermarket at 4 am. She was leaving the door unlocked all night for her husband and cooking his dinner every night; he had died some 20 years previously.

That lady was my mother. She certainly would not have understood a suggestion that she should opt for an assisted death. The DoLS was subsequently reinstated. This is not an unusual situation. If the noble and learned Lord, Lord Falconer, rejects these amendments, how does he consider that such vulnerable individuals can be protected from making this final decision, although they may not understand exactly what they are doing?