Laura King , Julie-Marie Strange | 14 February 2025

Assisted dying evokes strong opinions in an exceptionally complicated and ethically muddy context. Many politicians and professionals working in and around those dying, in palliative medicine, hospices, care homes, bereavement services and the like are truly divided on this issue, between a compassionate urge to help those in pain die with dignity if they wish to, and the potential for individuals to make a choice to die because of direct coercion or indirect (and perceived) pressure from relatives, carers and friends or over-stretched health services. The good arguments to both support or oppose the Terminally Ill Adults (End of Life) Bill affecting England and Wales, and the Assisted Dying for Terminally Ill Adults (Scotland) Bill, now at committee stage in respective parliaments, are complicated by the deep health inequalities that remain in the UK, and the lack of sufficient funding for good palliative and hospice care for those at the end of life. If individuals are in pain because of a lack of good care, or not able to access high-quality palliative services, their choice about whether to die is deeply affected. Vulnerable groups and those at the sharp end of health inequalities in the UK are most likely to be affected by the limited ability to access good care.

Palliative care and approaches to death have changed significantly over the last 150 years. In the nineteenth century, euthanasia was considered an intrinsic part of pain relief rather than a choice to die. As the subtitle to William Munk’s authoritative 1887 medical treatise on Euthanasiademonstrated, it represented medical treatment ‘in aid of an easy death’ rather than facilitating the definitive end to life. Choice and availability of better pain relief for those at the end of life has improved significantly into the twentieth century, ensuring opting to die isn’t the main or only means to address pain. At the same time, since the nineteenth century, advances in pharmaceuticals, such as penicillin and cancer treatments, alongside increasingly sophisticated medical technologies have extended life spans, including for those with terminal diagnoses, and improved mortality rates considerably. While many people are grateful for these shifts, they have also transformed social and cultural understandings of death from an inevitable endpoint (whenever it arrived) to a moment to be postponed for as long as possible. Death became, over the course of the twentieth century, a point of medical failure.

As much as advances in medical care and pain relief were and are to be welcomed, increasing numbers of people are facing long periods of poor health as part of terminal illnesses and conditions. Improvements to holistic care for those dying can be found in the twentieth century, particularly in the rise of the hospice movement following Cicely Saunders’ founding of St. Christopher’s Hospice in 1967. Hospice care focused on pain management and comfort, and care for the whole person, heralding an era of renewed focus on enabling a ‘good death’ as much as prolonging life. This drive to facilitate ‘good deaths’ harked back to nineteenth-century practices that prioritised spiritual and emotional care in addition to easing individuals’ physical suffering. By 2014, a World Health Assembly resolution called for World Health Organisation member states to improve access to palliative care, underlining that palliative care should be a core component of health systems.

Pivotal to current conceptions of enabling ‘good death’ are equal access to good health care services, choice and the exercise of agency. Indeed, these are central to arguments in favour of assisted dying. But the evidence from palliative care suggests that, despite dramatic changes in health, medical and social care in the twentieth century, access to high-quality palliative care remains deeply uneven. Let’s consider the example of domiciliary palliative care. Since the rise of histories and social commentaries from the late 1970s that celebrated the nineteenth-century as a ‘golden age’ of death – when families and friends took responsibility for supporting the dying at home in partnership with medical practitioners – dying at home has represented an aspiration for most healthy and terminally ill people. It emerged as a policy objective for UK government in the late 1970s (Department of Health & Social Security, 1979-80; Cmnd 8086). Select committee debates on the issue were couched in the rhetoric of ‘choice’, ‘independence’ and ‘community’ while being tied to imperatives to reduce social security expenditure. By the end of the 1980s, parliamentary rhetoric stated that creating a ‘free market’ in home-based palliative care represented ‘common sense and good value’ (see Roy Griffiths, ‘Community Care: Agenda for Action’, HMSO 1988; Government white paper ‘Caring for people. Community care in the next decade and beyond’, 1988-9; and House of Lords, Social Security Bill Debate, 22 June 1989; Social Services Committee, Eighth Report: ‘Community Care: Planning and Co-operation’, 1989-90).

Yet even as the domiciliary care model became entrenched during the 1980s and 90s, critics consistently pointed to core inequalities in an increasingly multi-cultural and racially mixed society, different causes of death (government responses to the emergence of HIV was a powerful indicator that not all lives and deaths were equal) and massive socio-economic disparities (continuing starkly into the Covid-19 pandemic). While dying at home may have represented a (cheap) ideal in theory, the lived experiences of dying at home in practice were often very different. The policy assumed homes were places of comfort and security and that there would be persons available (typically women) to undertake the emotional and dirty labour of caring for the dying.     

Taking an even longer view, ideas of dying at home as rooted in qualities of choice, individual agency and community traded on a nineteenth-century ‘golden age’ of death that only ever existed, at best, for a privileged few. Experiences of dying among the marginalised (those in poverty, racial, ethnic and religious minorities, the disabled, those living queer lives and so on) suggest that while for some, dying at home gave respite from discrimination and injustice, for many those injustices also meant limited access to good healthcare and services. These inequities were –  and are  –  not limited to home care; how individuals are cared for in a medical setting remains unequal too, with socioeconomic status continuing to affect care, while racialised and LGBTQ+ individuals are often treated significantly worse than their white and heteronormative counterparts.

The current bills demand we think through major historical influences, around changing medical and healthcare, but also in terms of inequalities across race, religion, income, gender identity and a whole range of other factors, to ensure any change to practices do truly serve –  with equity –  the search for a better kind of end to life.Please note: Views expressed are those of the author.

Laura King is a historian of families and emotional relationships in modern Britain, and has recently finished a project entitled ‘Living with Dying’. Her latest book, Living with the Dead (OUP, 2025), charts how families remember and connect to their deceased relatives and ancestors. She is Professor of Collaborative History at the University of Leeds.

Julie-Marie Strange is a historian with a long-standing interest in death and grief in nineteenth-century Britain. Her first book, Death, Grief and Poverty, 1870-1914 (CUP, 2005), explored the profound emotional lives of ordinary people experiencing bereavement. She has recently started a new research project exploring experiences of dying at home. She is Professor of Modern British History at Durham University.