Terminally Ill Adults (End of Life) Bill

Debate between Baroness Noakes and Baroness Cass

Committee stage
Friday 20th March 2026 Lords Chamber

[Baroness Noakes (Con)]

My Lords, I want to make a few points following the contribution from the noble Baroness, Lady Fox. First, she referred to MND and the problem with some people who appear to live quite a lot longer than expected. The real problem with MND is that these patients almost certainly will not qualify to be classified as terminally ill under the Bill. The speed of progression of the disease usually means that getting a six-month diagnosis is almost impossible, so motor neurone disease patients will find it very difficult to fit themselves within this. This is, I think, widely acknowledged.

Secondly, all this discussion has been based on the prognosis given by a doctor to his patient. The Bill requires it to be established that the individual is terminally ill for assisted dying to be available. That decision must be made by the first doctor, the second doctor and the panel. These are not doctors giving informal indications to their patients about the amount of time they may have left to live; these are people having to come to a professional judgment. Of course, if they cannot agree on that professional judgment, the decision will not be that an assisted death can be given. It seems that, in the context in which the prognosis is given—that is, to satisfy the definition of “terminally ill” in this Bill—there are many safeguards that would mean that we have a relatively safe definition of six months by the time all those who are involved in the process agree it.

[Baroness Cass (CB)]

My Lords, on the point made by the noble Baroness, Lady Noakes, the person or people who will make the best judgment about prognosis will be the treating team: the treating doctor and the multiprofessional team. I have always been somewhat dubious about how much those successive doctors can add to prognosis, as they will not be specialists in the area. I just make that point.

I am always gratified but slightly alarmed at the faith that noble Lords place in doctors. It was not always what I experienced in practice, when many of my patients arrived with an internet search knowing more than I did about the condition, especially as I worked somewhere where we often saw young people with rare disorders.

A number of things are getting conflated in this debate. When a previously young, fit person walks through the door with a cancer diagnosis, there will be a series of trials and data on the prognosis for that age group with that diagnosis. Then it narrows down as there are the specific features for that individual. Then they start treatment and, as the treatment goes along, your prognosis gets more individualised as they do or do not respond to the treatments they are being given. Ultimately, it may become clear to the treating team that that person is no longer responding to treatments, and it becomes a very individualised prognosis at that point. So although you may start off with statistics, which are very broad, you end up giving the best advice about what you see before your eyes—as the noble Baroness, Lady Hayter, said—in relation to how that patient is responding to treatment and how they are doing.

The further complication that stops you depending entirely on the papers that you have just read is where that person started off with diabetes, heart failure or a series of other complications. There just is not specific data for that complex of conditions that the patient may have, so it will be significantly dictated by clinical judgment, ideally by the whole multiprofessional team. We need to distinguish people with a clear cancer diagnosis, where there is lots of data, from people who have a mix of the more usual things that we see in the elderly population: cardiac problems, respiratory problems, diabetes, Parkinson’s—a whole complex of things. It then becomes, again, something that you cannot refer to in a textbook but something that you see in the state of progression of that person’s symptoms and their reducing response to treatment. I should sit down at this point, as I should not proceed further when my noble friend can speak to this with much greater authority.

Terminally Ill Adults (End of Life) Bill

Debate between Baroness Noakes and Baroness Cass

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.