Relevant documents: 32nd and 36th Reports from the Delegated Powers Committee, 12th Report from the Constitution Committee, Report from the Terminally Ill Adults (End of Life) Bill Committee
My Lords, my Amendments 4, 249, 257, 304, 337, 446 and 448 raise the eligibility for the provision of assistance under the Bill from 18 to 25.
There is no reason, either in law or in principle, why we should assume that 18 is the right age for eligibility for an assisted death. It is not only an arbitrary starting point; it is contrary to the mounting evidence of when the brain is fully formed, which I shall come to in just a moment. When I asked the Children’s Commissioner, Dame Rachel de Souza, whose role it is to promote and protect the rights of children and young people, what she thought of 18 being used as a cliff edge for eligibility under the Bill, she answered:
“The reality of life on the ground, as those of you who work with health will know, is that 18 is not really a thing … when it comes to the most vulnerable, that is extended to 25”.
She went on to say:
“I think that we are missing a trick by thinking somehow 18 is the cut-off. I really do strongly think that. I would like the committee to consider that”.
Noble Lords will be aware that there are a range of existing circumstances where 25 is already seen as a threshold to adulthood, instead of 18. This is particularly relevant when we consider vulnerable young people with a terminal illness, whom we need to consider in this legislation—lest we forget that children are not currently mentioned in the Bill.
The point was forcefully made to the Select Committee. The Children’s Commissioner said:
“They are the children I am worried about: children with special educational needs, children who are already in hospital with life-limiting diseases, children who have EHCPs—education, health and care plans—that provide support for them until the age of 25. The reason they do that is that they are vulnerable, whether it is mental health concerns, whether it is because they have had terrible lives and might have all sorts of problems, including suicidal ideation. It is a real concern”.
My Lords, I support this amendment in principle, based on the research in relation to cerebral development. I think it is well made and an example of something that we are really here to think through to enhance the Bill. However, I point out that the Bill excludes anybody with a lack of capacity, so several of the people that the noble Baroness referred to would not be entitled to consider assisted dying.
My Lords, I suggest that the noble Baroness, meaning absolutely well in a clearly very emotional area, has forgotten the real science. She is not a neuroscientist; indeed, I do not think that the commissioner is a neuroscientist. The greatest expert in the United Kingdom on teenage neuroscience is almost unquestionably Sarah-Jayne Blakemore, who works partly in London, partly in Cambridge and of course has been working extensively at UCL for a long time. She has studied teenagers in great detail, and it is very clear from her work on teenagers making decisions that they can make decisions in the right environment and in the right circumstances. I think one has to be very, very careful about making assertions about teenagers. There are many people well over the age of 25 who cannot make these decisions either. I think we have to be quite clear that we may need to take this sort of thing into consideration, but I do not think it is necessarily relevant to this amendment.
My Lords, I want to speak in support of the noble Baroness, Lady Berger. I will limit my remarks because some of them have already been made by previous speakers. I think the reality is that maturity is a scale and choosing to proceed with assisted dying at the age of 18 poses difficult questions, which we must grapple with, about the neurological maturity required for true, settled and informed consent on a matter of such gravity, and not just particular circumstances. I intend to speak in a subsequent group to Amendment 22 in the name of the noble Baroness, Lady Grey-Thompson, but some of the points I will make then are also relevant to this group.
I note that research undertaken by the Sentencing Council in 2024, which focused on aggravating and mitigating factors in sentencing guidelines, has this to say about age and maturity:
“Age and/or lack of maturity can affect … the offender’s responsibility for the offence and … the effect of the sentence on the offender. Either or both of these considerations may justify a reduction in the sentence”.
The report goes on to note:
“In particular young adults (typically aged 18-25) are still developing neurologically and consequently may be less able to: … evaluate the consequences of their actions … limit impulsivity … limit risk-taking … Young adults are likely to be susceptible to peer pressure and are more likely to take risks or behave impulsively when in company with their peers”.
I do not want to cross over into debate on the subsequent group, but this seems highly relevant to our deliberations on the appropriate age for assisted dying. Of course, age and maturity are mitigating factors only, and therefore discretionary, but it seems extraordinary to me that the principle of maturity is one which is accepted in a legal context, and there remain calls for dedicated sentencing guidelines for 18 to 25 year-olds in recognition of this, yet the Bill as drafted does not seem adequately to account for this in a similar manner with regard to the permanent decision to end one’s own life. I would be grateful if the noble and learned Lord, Lord Falconer, could comment on this when he responds to the debate.
My Lords, I have an amendment in this group and I support the noble Baroness, Lady Berger, in this. I just want to add to earlier comments. The transition from children’s to adult services at 18 is well known to be a very confusing and destabilising period during which key clinical relationships are lost and important elements of a young person’s history may not be carried forward. These factors are directly relevant to assessing decision-making capacity and identifying safeguarding concerns for individuals aged 18 and above who may seek assisted dying. I think that raising the minimum age would allow for any medical advances—for example, with emerging new treatments that might change a young person’s prognosis. It is important not to be too hasty.
I also want to comment on the Scottish Sentencing Council and to add that, again, there is something about the developmental process which is still under way which can increase susceptibility to influence, vulnerability to risk-taking and the likelihood of short-term, emotionally driven decision-making. We have only to think about the fact that in that age group, the biggest cause of death is actually accidental death. Research done by the Sentencing Council and other research shows that maturity may be delayed by adverse childhood experiences. It is therefore reasonable to assume that some young adults with serious illness may carry such developmental vulnerabilities into their decision-making around the end of life. The Sentencing Council guideline suggesting lower culpability and a greater capacity for change than in older adults endorses the suggestion that we should change the minimum age to 25. This is an irreversible decision. We need enhanced safeguards for this age group, and I support the amendments.
My Lords, let me just state that, for very different reasons, although I have a great deal of respect for both the noble Baronesses, Lady Lawlor and Lady Berger, in this instance I have serious qualms about these amendments in relation to raising the minimum age for receiving assistance to end one’s own life to either 21 or 25. I think we need to hold on to the standard age where we consider adult responsibility to begin—that is 18—as the Bill does. I worry that we are already getting ourselves into a tangle on age issues. For example, the proposal is now to lower the voting age to 16. I wonder how the sponsor of the Bill will hold the line at 18 when those newly enfranchised 16 to 18 year-olds start demanding equal entitlements from 16. Logically, those teens will have a point when they argue, “If you trust us to decide on the future of our country, why not trust us to decide on the future of our own fate if we fit the other eligibility criteria?” I would like some reassurances from the noble and learned Lord, Lord Falconer, that this age slippage will not happen, but also that 18 is a watertight age in terms of eligibility, and there are other amendments later on.
Conversely, I ask the noble Baronesses whether there is a danger of unintended consequences in using the argument that the young brain has not developed sufficiently at 18 to make such important decisions. It makes me anxious when neurodevelopment research is cited about cognitive development and a lack of maturity about anyone under the age of 25. That is used to challenge the decision-making capacity of anyone below the ages of 21 or 25. I fear that it could be used regressively. How can we trust 18 to 25 year-olds to vote, or be asked to take on any adult responsibilities, if their brain is still developing? Where are we going to end up? I think we need to avoid unintentionally institutionalising state paternalism that robs young adults of their individual rights and limits the choices on their own fate in various ways. The cultural shift to infantilise the post-18 cohort, which is a broader problem, is, in my opinion, regressive.
My Lords, I understand very much the points made by the noble Lord, Lord Winston, and the noble Baroness, Lady Fox. I come to this issue from a rather different position. I used to try a lot of cases, some of terminally ill young people, generally from the ages of 15 up to 25 or more. There were a number of cases of those with terminal illness, undoubtedly with capacity, who were also suffering from depression, not very surprisingly, or were confused as to what they really wanted. They came before me for all sorts of reasons unconnected with whether they should live or die from their perspective. What I was looking at was the medical evidence as to the sort of support that they ought to have.
Despite the neuroscience issue, which is important, and despite 18—or down to 16 under the present Government—being the age at which you are able to vote, I just raise whether you are looking at how much you care about the future of this country and what you care about for yourself. Do you want to die because you are going to die in the next few months? The doctors may be right or wrong about six months; we know that many diagnoses are inaccurate. This may be the most important decision of all to make: life or death? Consequently, I am concerned about the age of 18 from my own experience. Whether it should be 21 or 25 is arguable, but I am worried if it sticks at 18.
My Lords, I support the amendment from the noble Baroness, Lady Berger. It is reasonable to have these considerations about the different ways people think and feel at different times in their life. One of the big discussions we have more broadly about the Bill is about the cognitive capacities of old people, which are very important in their freedom of decision.
In a similar way, it is reasonable to talk about the cognitive capacities of very young people. In particular, one of the things that makes very young people different from older people is that they naturally have very little encounter with death; they are much less likely to have come across situations in which people die and people they know have died. They simply do not know what it involves. If it were banned throughout the world that anybody under the age of 25 would fight in a war, we would hardly have any wars. One reason why soldiers are prepared to fight in wars is that they do not understand death when they are very young. They are ready for anything.
There is often a very strong culture of suicide in young people, because it is a romantic idea. The poet Keats expressed it absolutely beautifully in his “Ode to a Nightingale” when he speaks about being
“half in love with easeful Death”,
and the joy of ceasing on the midnight with no pain. He knew of what he spoke, in a sense, because he was suffering from a terminal illness, and he died before he was 25.
As the noble Baroness, Lady Berger, and others have brought out, we need to think about the influences on young people who may go in that direction. If they suffer from a terminal illness, that becomes even more acute. Because of their lack of experience in these matters, they will be under greater pressure, quite possibly, to feel that suicide is the way out and is somehow a noble thing to do.
My Lords, the people we are talking about are dying, in suffering and in pain. They are not being offered; they are going to be asking. I think of a 23 or 24 year-old in pain and about to die, possibly within weeks or months, and we turn around and say, “I am really sorry. You have had children, taken big decisions in your life, taken career decisions and seen whatever has happened to your parents, but you cannot be helped in your last few days, weeks or months because you are only 24”. I find that extraordinary. The age of 18 is probably the right one. Can we remember that these people are dying, and they are suffering? Those are the people who will be applying for this.
My Lords, I rise with some caution, because these are deep waters. I think we should err on the side of caution. I support the noble Baroness, Lady Berger, because this is an entirely new process. Assuming the Bill comes into force in some form, the age can always be lowered in the light of experience; by experience, I mean that of the human brain and how people are considering these things.
What has prompted me to say this in particular is the report in the Times on 25 November of the study by Cambridge’s MRC Cognition and Brain Sciences Unit, which compared the brains of 3,802 people aged between zero and 90 years, using datasets of MRI diffusion scans, which map neural connections by tracking how water molecules move through the brain tissues. Very simply, this study found that the topology of the childhood brain runs from birth until the turning point at the age of nine, and then it transitions into the adolescent phase, an era that it found—this is completely dispassionate—lasts right up to the age of 32 on average. Our early 30s see the brain’s neural wiring shift into the adult mode, and I emphasise that phrase: adult mode. This is the longest era and lasts over three decades. A third turning point, around the age of 66, marks the start of an early ageing phase and, for those of us who are a bit older, the late ageing brain takes shape at around 83 years old.
I conclude by reading from the report:
“While puberty offers a clear start, the end of adolescence is much harder to pin down scientifically. Based purely on neural architecture, we found that adolescent-like changes in brain structure end around the early thirties”.
If that is the architecture, at this stage in the Bill we should be looking at 25 and not a younger age.
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Noble Lords will know that local authorities are responsible for preparing and maintaining EHCPs for children and young people with special educational needs up to the age of 25. Our local authorities have a statutory responsibility for young people up to this age, particularly those in care and those with special educational needs. It was more than a decade ago that the Department of Health, in its document Future in Mind, recommended an extension of child and adolescent mental health services up to the age of 25 to end the practice of discharging young people out of mental health services at 18.
In the context of criminal justice, I am mindful of the words of the noble and learned Lord, Lord Falconer, himself, who said in his speech in 2021 on the Police, Crime, Sentencing and Courts Bill that a whole-life term should never be imposed on an offender aged 18 to 20 but only on “somebody unequivocally an adult”. I hope that he will agree with me that death is not a less weighty matter than life in prison.
We have heard concerns during the progress of this Bill from experts who work with teenagers and young adults that it will be safer and more in line with the evidence to raise the minimum age for assisted dying to 25. It is by this point that the brain is more fully developed and decision-making capabilities are more secure. In general, the brain does not finish developing until a person is in their mid-20s, which is particularly the case for the prefrontal cortex, which governs our decision-making functions and our ability to think flexibly about potential outcomes.
Noble Lords may have seen research announced only last week by the University of Cambridge which suggests that the brain is fully developed only in our early 30s. I believe that we are here to make good law, and one way we do this is to listen when experts speak and to take their counsel. The simple fact of having enabled experts to give their evidence to this House over recent months does not amount to adequate scrutiny if that evidence simply languishes on the pages of Hansard, instead of being used to shape our work.
Of course, I know that an assisted death would be available only to young people with a six-month prognosis, but we know that it is not always accurate. It is, as I have learned, particularly difficult to get right with young people, who can go on to live for years beyond an initial terminal diagnosis. In its written evidence to the other place, the charity Together for Short Lives wrote:
“We are concerned that the requirement for an accurate prognosis to be provided for a person to be considered as ‘terminally ill’ may result in ambiguity when considering the eligibility of young people with life-limiting and life-threatening conditions whose prognosis is uncertain. Whilst the majority of adults only need palliative care at the end of their lives, many young people with life-limiting and life-threatening conditions require palliative care over a much longer period, often from birth or even in the womb. During this time, it is common for their conditions to fluctuate, meaning many young people may experience relatively long periods of stability. It is therefore much more difficult to provide an accurate prognosis and identify when a young person is moving towards their end of life stage”.
Together for Short Lives also recommends that under this Bill we consider how those aged 18 to 25 with EHCPs—education, health and care plans—will be affected.
The Bill as it stands is at risk of pushing young people with life-limiting conditions into thinking that reaching the age of 18 means that they are not obliged to consider whether they should continue to live or not. What does this say about how we value their lives?
We also cannot ignore the unique responsibilities faced by young people today. We know that social media has become a powerful driver of harm. Research from the Molly Rose Foundation, a suicide prevention charity, shows that vulnerable young people are disproportionately exposed to posts that glamorise suicide or present suicidal thoughts as normal, appealing or even fashionable. Alarmingly, 68% of young people with low well-being are being served this type of content. In such an environment, how can we claim to be safeguarding young people if, beyond the hospital bed, the digital world is telling them that their lives are not worth living? If this content is impacting young people when they are well, how much more so will it play on the mind of a terminally ill young person? To allow access to assisted dying at an age when external pressures are so pervasive, and when identity and resilience are still forming, risks compounding vulnerability rather than offering protection.
When families, carers and local services should be striving to provide the very best care, we would instead be sending them the confused and dangerous message that 18 year-olds are instead now ready to choose and plan their own deaths. This is of particular concern when we consider young people with learning disabilities, and how competence should be established in those cases, particularly given the fact that young people with learning disabilities receive worse healthcare in general, as evidenced by the National Child Mortality Database. In its learning disabilities and autism study, it exposed the fact that children aged four to 17 with a diagnosed learning disability accounted for 31% of all deaths, despite only 2.5% of children in the UK having a diagnosed learning disability.
There are challenges with a health service that misses lots of health issues for this group of children and young people because of communication and advocacy barriers. The 2023 report, Learning from Lives and Deaths—People with a Learning Disability and Autistic People, found that 42% of deaths of people with a learning disability were rated as avoidable, compared with 22% for the general population.
It is in this context, and for all the other reasons I have set out, that I am strongly persuaded that raising the age of eligibility to 25 is the right thing to do. I am also haunted by the words of one child that were shared with the Select Committee. The young person said:
“I’m in care. I’ve got disabilities. The Government will pay for me to die under this Bill, but it won’t pay for me to live”.
I conclude with a final contribution from the from the Children’s Commissioner, where she said:
“I would far rather that we erred on the side of caution, protecting those who have had terrible lives, terrible experiences, have been abused, have had their families turn them out, protecting those who are suffering from extreme mental illness, protecting those with special educational needs and disabilities, protecting anorexic children who are heading into adulthood, and saying, ‘Let’s err on the side of caution and go for 25’”.
I am clear that we must continue to say to children and young people, “Yes, your life matters. Even if it will be a short life, it matters”. We must amend the eligibility for assistance under the Bill to 25. I beg to move.
The autonomy on which the Bill is purportedly built must be grounded in safeguards commensurate with the irreversible nature of the proposed act. With regards to the age of eligibility, I do not believe the Bill as drafted meets this standard. For these reasons and more, I support the amendments in the names of the noble Baronesses, Lady Berger and Lady Lawlor, as well as those in the name of the noble Baroness, Lady Goudie, and the noble Lord, Lord Moylan.
Finally, I am very sympathetic to the concerns that have been raised here already. It might be worth considering some kind of carve-out for 18 to 25 year-olds on EHCPs, but that would be an exception, not a rule. Viscerally, the idea of any young person of 19 or 20 having a terminal diagnosis and then being offered the choice of an even earlier death fills me with horror, gives me the chills and is tragic. But I still think that 18—if tightly protected by the sponsors of the Bill—is adequate in relation to age safeguards. There are plenty of other safeguards that I am worried about without adding to them.
I also think that there is a problem of the Bill creating a culture, for the young in general, of suicidal ideation. However, these amendments do not resolve those broader problems.
I remember, at school, there was a very brilliant boy who was 18 and wrote a very short poem that just said, “If I should die, think only this of me: ennui”. It was a very clever thing to write, and he subsequently committed suicide aged 19. I ask noble Lords to think about what it might be like in such a situation at such an age.