In South Africa, where people die differently according to their bank balance, we urgently need the courage to acknowledge that true dignity requires both expanding access to life-affirming care and respecting the autonomy of those who face suffering that no amount of care can address, writes Leigh Meinert of Dignity South Africa in Daily Maverick.
She writes:
Last month at the Desmond & Leah Tutu Foundation, Yvette Andrews told a story no one wanted to hear, but everyone needed to. Her friend Di – a phenomenal dancer, a woman who filled rooms with laughter and inspired countless others – had died screaming in agony despite having access to the best palliative care.
“Please just kill me,” Di had begged during her final days, on that terrible night when both women found themselves on the floor, exhausted and heartbroken. Yvette, a trained nurse with years of palliative care experience, could only hold her friend and promise to keep caring, knowing that “orange was not my colour” – a reference to the prison uniform she’d face for helping.
The story haunts me, not just because of its raw honesty about suffering, but because it cuts through the false choices that dominate discussions about end-of-life care in South Africa.
We are told we must choose between palliative care and assisted dying, as if they are opposing armies rather than complementary approaches to human dignity.
Reality behind the rhetoric
In my capacity as operations manager of Dignity South Africa, medical doctors and hospice leaders regularly share tragic stories about unbelievable suffering. These professionals admit that, when the time came, they made the ultimate sacrifice – endangering their own lives by helping to ease someone else’s passage.
In those moments, compassion won the day, and these individuals rarely live with regret.
Yet publicly, we maintain the fiction that this doesn’t happen, that the choice between a “natural” death and a dignified death is somehow morally clear-cut. We ignore the reality that in South Africa today, only those with resources to fly to Switzerland can access assisted dying legally, while everyone else must either suffer or hope their doctor is brave enough to risk imprisonment.
This is not just morally indefensible – it’s typically South African in its inequality. Suffering, after all, does not discriminate based on race, class or gender. But our healthcare system certainly does.
Friends, not foes
When Dignity South Africa refined our mission earlier this year, we placed advocating for high-quality palliative care at the very top of our agenda. This wasn’t political positioning, it was recognition of a fundamental truth that palliative care advocates like Hanneke Lubbe, the founder and CEO of Hospice Bloemfontein, have been telling us: if people could access high-quality palliative care, most would not need to seek assisted dying.
The keyword here is “most”, not “all.”
During our discussion, Lubbe spoke with passion about the privilege of seeing people “as the person they are when illness has stripped down everything and just the core of who they are is left”. She described the healing that can happen in suffering, the opportunities for reflection and reconciliation that come in those final months and weeks.
She is absolutely right. Palliative care, with its focus on total pain – physical, emotional, spiritual, and social – offers profound dignity to the dying and their families. It should be available to all South Africans from the point of diagnosis with a life-threatening illness, not just in the final days when “curative treatments have failed.”
But Lubbe also acknowledged the complexity of what she witnesses daily. Even excellent palliative care, she reminded us, “is hard. It’s messy and it asks a lot”.
And sometimes, as Yvette’s story demonstrates so painfully, it is not enough.
The South African context
Our context makes these discussions even more urgent. According to the World Health Organisation (WHO), only 14% of people who need palliative care worldwide currently receive it. In South Africa, where more than 80% of citizens are uninsured and healthcare providers spend an average of seven minutes per patient, the figure is undoubtedly worse.
We live in one of the most unequal countries in the world. We have a health system that fails the poor daily. We have languages that don’t even have words for “assisted dying” or “euthanasia”, making these conversations nearly impossible in many communities.
Critics argue that implementing assisted dying in such a context would create not just a slippery slope, but a “runaway train”. They worry about coercion, about the vulnerable being pressured into ending their lives because proper care is too expensive or inaccessible.
These are valid concerns that any legislation must address with the strongest possible safeguards. But they are also arguments for fixing our health system, not for perpetuating a situation where only the wealthy have choices about their deaths.
Ubuntu and individual choice
Perhaps the most profound challenge to assisted dying in South Africa comes from ubuntu – the philosophy that “I am because we are”. Critics argue that assisted dying, with its emphasis on individual autonomy, flies in the face of African communalism where family and clan decisions take priority.
But through careful listening and authentic curiosity, we are learning that ubuntu may actually support compassionate choices about dying. African traditional communities have rituals for when people are ready to return to their ancestors.
Christian ministers speak of going home to God. As Archbishop Tutu himself wrote: “In refusing dying people the right to die with dignity, we fail to demonstrate the compassion that lies at the heart of Christian values.”
The ubuntu framework might actually demand that we campaign not under the banner of “my life, my choice” but “our lives, our choices”. When someone dies in distress, the ripple effects extend far and wide. Their suffering becomes their family’s suffering, their community’s suffering – and one day the bell will toll for each one of us.
A path forward
South Africa stands at a crossroads. We can continue to pretend that these impossible choices don’t exist, that suffering somehow ennobles us, that maintaining the status quo serves anyone other than our own moral comfort.
Or we can have the difficult conversation that Yvette Andrews courageously started.
The evidence from countries that have legalised assisted dying shows that palliative care uptake and resourcing typically increase considerably. Just this month, France’s Assisted Dying Bill was passed through its National Assembly, in tandem with a Palliative Care Bill that ensures significant investment in palliative care.
When society takes end-of-life care seriously enough to offer all options, it tends to invest more in all forms of care.
We need both excellent palliative care and the option of medical assistance in dying as a last resort for irreducible suffering. We need advanced directives and living wills to be legally recognised. We need morphine to be available in rural clinics and hospice care to be funded properly. We need healthcare workers who have time to have real conversations with their patients.
Most of all, we need the courage to acknowledge that in a country where people die differently depending on their bank balance, true dignity requires both expanding access to life-affirming care and respecting the autonomy of those who face suffering that no amount of care can address.
Three months after her friend’s death, Yvette Andrews closed her story with these words: “These issues are hard and complex and no deliberations will ever make them easier.”
She was right. But as Carl Jung reminded us, and as Di would have appreciated: “Know all of the theories, master all of the techniques, but as you touch a human soul, just be another human soul.”
In South Africa, where ubuntu teaches us that we are all connected, being truly human means ensuring that everyone, regardless of their wealth or postcode, has access to both excellent living and dignified dying. The time to act is now.
Leigh Meinert is operations manager of Dignity South Africa and former advocacy manager of the Association of Palliative Care Centres. She trained as a death doula and has spent more than 20 years working to make quality care and education accessible to all South Africans.
See more from MedicalBrief archives:
France votes to legalise assisted dying
UK MPs support Bill to legalise assisted dying
SA woman has assisted suicide after winning medical negligence claim
Euthanasia activist says SA doctors support legalising assisted dying
Assisted death must be decriminalised – SA mental health practitioners