04-07-2025
Navigating death with dignity: The imperative for meaningful conversations about palliative care
My intention is not to change anyone's mind on the deeply personal and complex issue of physician-assisted suicide (PAS). Rather, it is to offer insight into our world as palliative care professionals — both as representatives of the Association of Palliative Care Centres South Africa, and as individuals who walk alongside patients and families through some of life's most vulnerable and profound moments.
We live in a society that tends to avoid conversations about death. We reduce it to suffering and we hide it away. Yet, it's in these very spaces where some of the most meaningful human experiences unfold. Engaging in honest dialogue about death and dying is not just helpful, it's necessary. We must sit with the discomfort — not to find easy answers but, rather, to start asking better questions.
The article referenced above agrees on many points. We, too, acknowledge that palliative care is for all, and assisted dying is for very few. But here lies the tragedy. Out of 56.8 million people globally who require palliative care each year, only 14% receive it. And in South Africa, this picture is even more dire. Access remains limited, fragmented and underfunded. We are not dismissing the suffering of those few who may consider PAS, but we are profoundly concerned that the broader system is not yet equipped to care for the many.
As palliative care professionals, we care for people with serious illness across all domains of their humanity — physical, emotional, cultural, social, and spiritual. Our work is not to remove all difficulty, but to make the experience of dying meaningful, and dignified. We believe, as Viktor Frankl once said, that 'suffering ceases to be suffering at the moment it finds meaning'.
So how do we offer that possibility? Through intentional presence. By listening. By exploring the full scope of what our patients experience. When a patient expresses a wish to hasten death, we take that seriously, but we do not see it as a conclusion. We see it as the beginning of care — a doorway to deep, holistic conversations. What lies beneath that wish? Is it fear? Is it loneliness? Is it untreated pain, unresolved trauma, or existential distress?
Low healthcare literacy
This lies at the heart of our concern. While proponents of PAS may point to autonomy and individual choice, we must also acknowledge the conditions shaping those choices. South Africa remains one of the most unequal societies in the world. More than 80% of our population is uninsured. Despair and poverty exacerbate suffering. Our healthcare system is under immense strain, and healthcare literacy is low. In this context, how can we be certain that PAS will not disproportionately affect the vulnerable? Can we truly safeguard against coercion, subtle or otherwise?
And another important question. Are we confident that our legal and healthcare systems are equipped to handle the complexity of PAS? In practice, our clinicians often spend as little as seven minutes per patient. In that time, how do we facilitate the kind of thoughtful, multilingual and culturally sensitive conversations that PAS requires? Who is present in these conversations, and how do we ensure that they are understood? There isn't even a word for euthanasia in isiXhosa. In African traditions, decisions around death are communal, not individual. Introducing a concept like PAS without respecting cultural diversity risks deep alienation.
For those of us involved in hospice care, every day we accompany people through the final stages of life. We are present in those sacred, difficult and often transformative moments. Yes, there are cases where we ask ourselves if we missed something and could PAS have helped this person? But when we reflect deeper, we also recall what emerged in that time of waiting — healing conversations, long-awaited forgiveness, moments of connection that cannot be replicated or rushed.
We don't romanticise death. It will always be hard. Yet, it can also be a time of profound human dignity. We have seen patients who, for the first time, felt truly seen; spouses who found purpose in caregiving; families who rediscovered each other and individuals who reached a place of acceptance, even belonging, at the end. These moments are why we fight for palliative care.
We agree that autonomy matters. That's why we advocate for earlier conversations about treatment goals, values, and living wills. But autonomy is not only the right to choose death, it's also the right to be supported to live meaningfully until the end. We want everyone's voice to be heard, especially when they can no longer speak for themselves.
So perhaps the question we must ask is not whether PAS should be legal, but whether legalising it in South Africa, at this moment, would do more harm than good. Are we ready for this? Have we done enough to ensure that no one chooses death simply because they had no access to dignified care?
Palliative care does not hasten or postpone death. It affirms life and recognises dying as a natural process. And we continue, every day, to witness dignity, quietly and powerfully in the lives of those we serve.
