How should we die? Who chooses when life ends? Is a “good death” possible?
Such questions may seem ill-timed. What choice had the innocent dead in the wars in Ukraine, Palestine and around the world, in famine in Yemen and South Sudan, or in health poverty in Britain? Yet on 29th November, the question of a good death was partly answered as Labour MP Kim Leadbeater’s Terminally Ill Adults (End of Life) Bill passed its second reading in the House of Commons. The debate, however, goes on, with a committee of MPs—twice the usual number for private members’ bills—appointed to closely review the legislation ahead of a third and final reading later this year.
The bill would give adults in England and Wales with “an inevitably progressive illness, disease or medical condition which cannot be reversed by treatment”, likely to die within six months, the right to end their life. The person must have “a clear, settled and informed wish” to die, without being “coerced or pressured by any other person” (an offence punishable by up to 14 years in prison), and make two signed declarations after two “periods of reflection” to ensure both their capacity and intention. Two “assessing doctors” and a High Court judge must approve the application after thoroughly examining the person, and the court may question one or both of the doctors before approval.
Doctors will not be obliged to take any part in the process, but if unwilling, they must refer the person to a doctor who is prepared to assess eligibility. If the application is approved, doctors will “provide that person with an approved substance”, “prepare that substance for self-administration by that person”, “prepare a medical device which will enable that person to self-administer the substance” and “assist that person to ingest or otherwise self-administer the substance”. The final act, however, must be taken by the person who wishes to die—not their doctor.
It is not the first time MPs have debated assisted dying. In 1936, Arthur Ponsonby’s Voluntary Euthanasia (Legalisation) Bill was defeated in the Lords. The Suicide Act (1961) made “encouraging or assisting the suicide or attempted suicide of another person” a criminal offence punishable by up to 14 years in prison. Attempts to change parliamentary opinion failed in 1969, 1970, 1985 and 2015. On one side, Christian Action, Research and Education (CARE), founded as the National Festival of Light, has been lobbying for “a Christian voice into political life” since 1971, and claims to have “helped stop multiple assisted suicide bills” (alongside advocating against abortion rights and gay marriage). On the other, Dignity in Dying (founded as the Voluntary Euthanasia Legalisation Society), which has had many high-profile patrons including AC Grayling, Terry Pratchett and Patrick Stewart, has lobbied the government since 1935 to legalise assisted dying.
The question of a good death, of dying with dignity, however, has a far longer history. Philosophers, poets, divines and those about to die have long pondered and refined ars moriendi: “the art of death”. This tradition, which emerged in classical philosophy before flourishing in medieval devotional literature, was obviously religious in scope: concerned less with the body in the here and now than the soul in the hereafter. Yet it would be unwise to ignore the rich heritage of meditations on dying afforded by ars moriendi, for it grapples with some of the political, moral and ethical arguments about death that still shape assisted dying debates today.
In the Phaedo (circa 360BC), Plato—via his mouthpiece Socrates—says “the true votary of philosophy... is always pursuing death and dying” because the task of philosophy is to separate the contingent from the necessary, the corporeal from the spiritual, a process perfected by the separation of the soul from the body in death. “Any man who has the spirit of philosophy, will be willing to die,” says Plato, “but he will not take his own life, for that is held to be unlawful.”
The later Laws (347BC), written very near Plato’s death, however, suggested an exception to the prohibition on suicide for those “under the compulsion of some painful and inevitable misfortune”—but stressed that “a physician... convicted of poisoning, shall be punished with death”. We might note, as Jacques Derrida did, that in Plato’s work pharmakon could signify both poison and cure. Plato hints that terminal illness or “inevitable misfortune” might justify loosening laws against suicide. But he could not approve of a medical practitioner causing death—unable, perhaps, to see the cure in the poison.
Death was everywhere in medieval Europe, not only in mortality itself but in what Princeton professor D Vance Smith calls the “extravagant mortuary forms” that dominated everyday life, such as “chantry chapels, mortuary rolls, the daily observance of the Office of the Dead, Purgatory”. Nor should we forget that the Crucifixion—a slow, agonising death, yet also a willing and voluntary self-sacrifice—was endlessly remembered in sculpture, paintings, prayers and each Sunday at mass.
Henry Suso, a 14th-century German Dominican friar, in the fifth chapter of Horologium Sapientae (The Clock of Wisdom, circa 1328–30), advised “how we shall learn to die”. He stressed that the dying person should not be given false hope of “amendment” and the “fruit of heal” when recovery is impossible. Although he did not advocate suicide, Suso believed “the friends of bodies be enemies to souls”—highlighting the potential conflict between assisted dying and the Hippocratic injunction never to “counsel” or “administer poison”, and its modern revision in the Declaration of Geneva’s pledge to “maintain the utmost respect for human life”. Is keeping someone alive—being a “friend to the body”—justified when their quality of life—if we wish to avoid the language of the “soul”—has already gone?
Ars moriendi became vital during the Black Death (1347 to 1353), which halved Europe’s population, making preparation for death urgent (many “went peacefully to bed and were dead the next morning”). The plagued killed many clergy who performed their last rites. In January 1349, Ralph of Shrewsbury, bishop of Bath Wells, sent a letter to his diocese recommending that those dying “without parson or priest” could make their last confession to anyone present or, if alone, “faith must suffice”. Two extraordinarily popular works, Tractatus artis bene moriendi (Treatise on the Craft of Dying, circa 1415), and the shorter, illustrated Ars Moriendi (circa 1450, which gives its name to the genre) became the DIY blueprint for a good death in dire times. It cannot be purely coincidental that the assisted dying bill, the latest attempt to refine the art of dying, emerged after a devastating pandemic.
The English print pioneer William Caxton translated the Tractatus as The Book of the Craft of Dying (1490). Of course, it was impossible for Caxton to sanction suicide, let alone assisted dying. Yet when he says the dying should not “dread” but approach death “gladly and wilfully”, while also “suffer[ing] it patiently”, he hits upon an enduring problem. Should people die gladly and wilfully, or should they suffer until the end?
There is a striking parallel between the precautions in the assisted dying bill and Caxton’s ars moriendi. Those “labouring fast [...] endward”, he says, must submit to “seven interrogations” “while they have reason with them and their speech” and “in their last end should be examined, enquired, and informed, more certainly and clearly” to determine if they fully comprehend their state. For Caxton, this was to ensure the dying are “saved everlastingly”. But these interrogations also anticipate the medical and legal examinations and “periods of reflection” enforced by Leadbeater’s bill. Consulting ars moriendi shows us that the assessment, declaration and witnesses of assisted dying will form a sort of secularised last rites, a quasi-sacral seal of the dying person’s final testament that harks back to the foundational texts of the art of dying.
Perhaps the most famous questioning of the unlawfulness of suicide in literature comes from Shakespeare. In his first soliloquy, Hamlet—not dying but certainly depressed, “distracted” and on the verge of a breakdown—complains:
O, that this too too solid flesh would melt
Thaw and resolve itself into a dew!
Or that the Everlasting had not fix'd
His canon 'gainst self-slaughter!
If Hamlet railed against the injunction on suicide, then Rabindranath Tagore struck a different note, writing in Fruit-Gathering (1916): “Let me not pray to be sheltered from dangers but to be fearless in facing them. / Let me not beg for the stilling of my pain but for the heart to conquer it”. Dylan Thomas also urged against giving in to an easy death: “Do not go gentle into that good night”, but “Rage, rage against the dying of the light”. However, if pain cannot be stilled, then perhaps John Keats’s “easeful Death” might be preferable? Indeed, choosing one’s own death might be a sort of victory over what Plato called “inevitable misfortune”.
“Euthanasia” comes from the Greek εὐθανασία meaning “good death”. It entered English in the early modern period, when it meant an organic, natural, and easy death. Edmund Burke wrote of the euthanasia of age, and David Hume described “Absolute monarchy” as “the easiest death, the true Euthanasia of the British constitution”. Its meaning shifted, however, in the 19th century, as advocates for assisted dying (as we would recognise them now) campaigned for “voluntary euthanasia”. In 1871, Samuel D Williams wrote in an essay for the Birmingham Speculative Club:
That in all cases of hopeless and painful illness it should be the recognized duty of the medical attendant, whenever so desired by the patient, to administer chloroform — or such other anaesthetic as may by-and-by supersede chloroform — so as to destroy consciousness at once and put the sufferer to a quick and painless death; all needful precautions being adopted to prevent any possible abuse of such duty; and means being taken to establish, beyond the possibility of doubt or question, that the remedy was applied at the express wish of the patient.
More than 150 years ago, Williams fairly perfectly outlined the major issues MPs now face. Should doctors prescribe death? What “needful precautions”, if any, can prevent abuse? How are we to judge the “express wish of the patient” for death?
There are compelling political, moral and ethical arguments for and against assisted dying. Why shouldn’t the sovereign individual have the freedom over their own death? Why must the law prioritise—some may say impose—suffering over a dignified death?
However, will assisted dying one day be seen as a cost-effective alternative to palliative end-of-life care for a cash-strapped health service? How long before the criteria for “assessing doctor” begin to slide? Will we see underqualified assisted dying associates filling in for overworked doctors, as anaesthesia associates and physician associates have done, with grave consequences? What happens when—as seems bleakly inevitable—a fully privatised NHS puts the power of death in the hands of pharmaceutical and medical insurance conglomerates motivated neither by the sanctity of life, nor by dignity in death, but by shareholders’ profits?
These concerns are for MPs to debate. They would do well to consult the ars moriendi tradition to learn how the question of suicide and assisted dying has been posed for thousands of years. The answers, though, remain far from clear.
