In October 2022, the Canadian department store chain La Maison Simons released an ad as part of a new national brand campaign. In the ad, a woman walks barefoot along a beach, tracing circles in the sand, moving through candlelit forests and a dreamlike gathering of friends, framed by dancers and soft light. Her voiceover is calm, reflective, resolved. “Even now,” she says, “as I seek help to end my life … there is still so much beauty.”
The film, titled “All Is Beauty,” quickly went viral, praised by some as courageous and condemned by others as dystopian.
Before the ad aired, the woman in the film, Jennyfer Hatch, a 37-year-old musician from British Columbia, had already ended her life by medically assisted suicide. Earlier that summer, in June 2022, Hatch had spoken to CTV News under the pseudonym “Kat.” She described the “extreme pain” of Ehlers-Danlos syndrome, a connective-tissue disorder that often causes chronic pain, and the repeated failures of a system that left her emaciated and unsupported. She told the network that while specialized referrals went nowhere and housing support stalled, her application for assisted death was approved in just weeks. “It is far easier to let go than keep fighting,” she said, noting she sought medically assisted suicide as a “last-ditch effort” because she could not get help to live.
Assisted death for the chronically ill and disabled is now routine in Canada. In 2024, the most recent year in which official government data is available, 16,499 people died under the federal medical assistance in dying, or MAID, system, which represents about 5.1 percent of all deaths in Canada that year. The first year MAID was legalized, 2016, about 1,018 people reportedly died through this program (MAID deaths did not have to be reported for the first few years). And Canada isn’t alone. In 2024, nearly 10,000 people died in the Netherlands through what the government calls euthanasia; nearly 4,000 people died in Belgium that same year through medically assisted death.
The reasons for seeking government help to end life are also expanding in the world’s liberal democracies: prolonged suffering, chronic illness, disability, mental disorders and even aging are increasingly framed not as conditions to be endured or treated, but as diagnoses that can certify eligibility for death.
In 1994, Oregon voters approved the Death with Dignity Act. When the law went into effect in 1997 after legal challenges, Oregon became the first state to legalize physician-assisted death; today, the practice is legal in 13 states, plus Washington, D.C., including new statutes in Illinois and New York that will be taking effect later this year. Twelve state legislatures — including Arizona, Iowa and Kentucky — will consider medical aid in dying bills this year.
In the United States, most jurisdictions that have embraced assisted suicide still require a six-month terminal prognosis. But even here, the narrow exception is under strain. In Colorado, patients with anorexia have been approved for and died by medically assisted suicide within the past few years. And experts I spoke with confirmed that doctors and advocates are already experimenting with how far that logic can extend. Beginning in March 2027, doctors in Canada will be able to administer lethal injections to people with anorexia and severe mental disorders.
For proponents of expanded death options, the imperative is clear: Competent adults should not be forced to endure lives they find unbearable. But skeptics warn that when “subjective suffering” replaces imminent death as the qualifying condition, the question shifts from pain and compassion as the natural end approaches to long-term subjective suffering and personal, familial and societal burdens. And once these subjective perceptions trump clinical markers, they argue, the precautionary barriers fall.
Origins of the debate
The modern debate over assisted suicide began in England in 1870, when Samuel Williams, a Birmingham businessman and amateur philosopher, published an essay arguing that physicians should be permitted to use chloroform to end the lives of patients facing a painful, terminal death. Williams grounded his case in a dual logic. He focused first on the “needless pain” of the deathbed, arguing that it was cruel to prolong the agony of a hopeless illness. But he also advanced a utilitarian claim: Once a sufferer became a “heavy burden” on family and society, the obligation to preserve that life began to fade.
The British medical establishment responded with horror, arguing the practice would dismantle the trust on which medicine depended. In 1887, Dr. William Munk, a fellow of the Royal College of Physicians, articulated a competing vision that would come to shape modern end-of-life care for the next century. Munk argued that doctors must never intentionally hasten death, but that they do have a “sacred duty” to relieve suffering through aggressive symptom control, even when such treatment carries the secondary risk of shortening life. The distinction between easing pain and inducing death became the ethical foundation of modern palliative care. It also became an enduring fault line that has widened in recent years.
The argument in England over assisted dying did not disappear. It merely migrated into other intellectual currents before returning to medicine decades later. In 1931, Dr. C. Killick Millard, a respected public health reformer, argued for voluntary euthanasia in cases of incurable illness. In 1935, Millard co-founded the Voluntary Euthanasia Legalisation Society. At roughly the same time, Millard also advocated compulsory sterilization of the “feeble-minded and mentally deficient,” a eugenics policy he defended as rational, humane and socially responsible. Millard was confident that medical judgment could determine when a life had crossed from heroic treatment to pointless burden.
The distinction between easing pain and inducing death became the ethical foundation of modern palliative care. It also became an enduring fault line that has widened in recent years.
During World War II, Switzerland opened an unexpected legal path for assisted suicide. Suicide itself had never been illegal, but revisions to the criminal code in 1942 specified that assisting suicide was a crime only if motivated by “selfish interests.” The implication that unselfish suicide assistance must be legal lay largely dormant until the early 1980s. It was then that private groups began offering protocols, counseling and practical assistance. A physician’s prescription remained necessary to obtain the lethal means, but scrutiny was minimal and the center of gravity lay in the private sphere. Switzerland had demonstrated a new possibility: assisted death grounded not in medical judgment but on the law’s silence. Switzerland thus answered for itself a key question that each nation in Europe and the West would soon tackle in its own way: Where do the rights and moral burdens fall in this debate, with the patient, the physician, the courts or the administrative state?
In the Netherlands, courts began tolerating physician-assisted death in the 1970s, beginning in 1973 when a physician received a symbolic suspended sentence for ending her terminally ill mother’s life. Dutch judges later affirmed that doctors might face tragic cases in which their obligation to relieve suffering conflicted with the ancient prohibition against ending life. Over time, informal “due care” standards emerged through medical practice. And in 2001, the Dutch parliament codified euthanasia and physician-assisted suicide for unbearable suffering that lacked the prospect of improvement.
Then there is Canada, which has moved further and faster than any other country in legalizing physician-assisted death and what qualifies. In 2015, the Canadian Supreme Court struck down the ban on assisted suicide, launching what Canadians now call medical assistance in dying, or MAID. Parliament responded in 2016 by codifying the decision but limiting MAID eligibility to those whose natural death was “reasonably foreseeable.” Five years later, after a Quebec court ruled in favor of disabled plaintiffs seeking MAID, Parliament opened eligibility to people suffering chronic illness and disabilities with no prognosis of pending death. Nowhere is this trend more pronounced than in Quebec, which now holds the highest percentage of assisted deaths of any known political jurisdiction in the world. In the fiscal year ending March 2025, MAID accounted for 6,268 deaths, a staggering 7.9 percent of all deaths in the province, representing more than one in every 13 residents who died last year.
These laws don’t ever get tighter. They only get looser. They only expand to make them faster, cheaper and include more subsets of people.
That is the context now facing Britain’s House of Lords in the United Kingdom, a domain where voluntary euthanasia was boldly proposed in 1935 and vigorously rejected, and where peers are now debating the experiences of other nations.
Looking around the post-1973 landscape, skeptics fear that once assisted dying is legalized, it will not remain contained. “These laws don’t ever get tighter. They only get looser,” patient advocate Matt Vallière told me. “They only expand to make them faster, cheaper, and include more subsets of people.” As executive director of the U.S.-based Patients’ Rights Action Fund, Vallière worries that slippage is inevitable, as subjective suffering replaces imminent death in health systems that struggle with cost, scarcity and unequal access.
No law instructs caregivers or administrators to favor the less costly outcome, Vallière notes. But over time, the system sorts cases on its own. Patients encounter delays, denials and exhausted alternatives, while assisted death remains reliably available. When eligibility turns on subjective suffering, loss of dignity, dependence or being a burden, the line between medical judgment and social failure blurs. What begins as a choice in extremes becomes the option of least resistance. Take, for example, the current debate in Colorado over terminal anorexia. It is not an outlier. It is a stress test.
A contested diagnosis
For decades, anorexia nervosa was understood as a treatable but stubborn mental illness, for which recovery was always the goal. Then in 2022, Dr. Jennifer Gaudiani, an eating-disorder specialist in Denver, proposed a new clinical subcategory: “terminal anorexia.” Gaudiani argued that for a small subset of “brilliant” and “exceptional” patients, insistence on recovery was cruel. She proposed that for treatment-resistant patients, refusal of food should be viewed as a terminal physiological state to be managed, not cured, and potentially justifying a lethal response.
Gaudiani published the cases of three patients with severe anorexia, for two of whom she personally helped obtain lethal prescriptions. The most revealing case was that of “Alyssa,” a 36-year-old academic who, Gaudiani wrote, described herself as a “dead girl barely walking.” To fit Alyssa into Colorado’s legal requirement of a six-month terminal prognosis, doctors concluded that “if Alyssa abandoned her attempts to consume a higher meal plan,” she would die within six months. The outcome thus hinged not on the disease, but on the patient’s refusal of care.
Gaudiani’s publication triggered immediate backlash. In a systematic review published in Frontiers in Psychiatry in 2024, researchers Chelsea Roff and Catherine Cook-Cottone excoriated the proposed category. They argued that “terminal anorexia” lacks diagnostic validity and falsely treats prolonged illness as evidence of irreversibility, despite extensive clinical literature documenting recovery after decades of severe disease. Roff, the founder of the nonprofit Eat Breathe Thrive, and Cook-Cottone, a psychologist and professor at the University at Buffalo, both disclosed their own lived experience recovering from severe eating disorders — Roff’s body mass index had once been in single digits. “Terminal anorexia,” they concluded, is a “pseudo-diagnosis.”
If the proposal alone were not enough, critics were stunned by Gaudiani’s use of aspirational language that elevated the anorexic patient’s refusal of care from illness to virtue. She described patients as “brave, suffering individuals” who deserve to choose the “time, place, and way of release.” She characterized “Alyssa” as having “clear, incisive writing” just days before her death — offered as proof that, though she was starving, she had the “insight and cognitive capacity” to choose suicide.
Critics noted that people with anorexia are already vulnerable to skewed aspiration and distorted self-concept. To frame self-starvation as evidence of clarity risks converting pathology into proof of autonomy. Under sustained criticism, Gaudiani in 2024 retracted her use of the term — but not before, as Cushla McKinney, a senior research fellow in the Department of Pathology and Molecular Medicine at the University of Otago, put it to me, “breaking the Overton window a bit.”
Terminal anorexia remains an active fault line. Roff and Cook-Cottone identified at least 60 assisted-death cases for eating disorders worldwide between 2012 and 2024, including in the United States. U.S. reporting laws are opaque. Colorado officials confirmed that anorexia-related assisted deaths have been reported, often categorized under “severe protein-calorie malnutrition.” That classification spiked from zero cases prior to 2021 to 12 cases between 2021 and 2023.
Meanwhile, in Canada, all such machinations will soon be moot, since the requirement for a reasonably foreseeable death has been abolished for the disabled and chronically ill — and in March 2027 mental illness will qualify as a sole underlying condition. At that point, terminal anorexia will no longer need a back door.
Canada’s expansion
Canada’s shift from banning assisted suicide to embracing it was quite sudden. In 2015, the Supreme Court ruled that people with “grievous and irremediable” conditions had a right to an assisted death. Parliament tried to temper this, restricting eligibility to those whose death was “reasonably foreseeable.” But in 2019, a Quebec lower court overturned that restriction. Rather than appeal to the Supreme Court, the federal government acquiesced. In 2021, it formally opened “Track 2,” expanding eligibility to the disabled and chronically ill, with mental illness to follow.
Bioethicist Trudo Lemmens, a professor at the University of Toronto, describes this sequence as political jiujitsu. That is, the government avoided a divisive legislative battle by treating a massive expansion of assisted death as a legal necessity rather than as a matter of public debate and consensus.
The fierce debate over expansion that was forestalled in Parliament still goes on, but it is now retrospective rather than policy-shaping. Lemmens argues that in a system with frayed social safety nets, the “choice” to die is a mirage. “You can see the kind of normalizing pressure. This is how people leave this earth now,” he said. Jocelyn Downie, a legal scholar at Dalhousie University in Halifax, Nova Scotia, and a key architect of the current policy, rejects this as cruel paternalism. For Downie, autonomy is the baseline. The state has no right to force individuals to endure suffering while it attempts to repair broader social failures. “To say you can’t have MAID until we have alleviated all poverty in the country is cruel,” Downie said. “You’re holding an individual hostage to systemic failures.”
Downie sees assisted dying not as shocking or new, but simply as an extension of health decisions already made on a daily basis. A “Do Not Resuscitate” order for a terminal patient, she argues, is closely akin to assisted death. The effort to draw a categorical line at assisted death, she says, “collapses under scrutiny,” because there is “no morally sustainable distinction” between withdrawing life support and administering a lethal injection by competent request. In both, clinicians act at a patient’s request, knowing death will follow.
Skeptics argue that Downie’s logic makes protective barriers impossible to sustain. This expansion has, for example, allowed the Canadian system to quietly address what is often described as the “tiredness of life” associated with old age. Canada isn’t alone on this expansion of logic. Lemmens notes that after Belgium removed the requirement for terminal illness, the concept of “polypathology” followed close behind. Polypathology refers to the accumulation of common age-related ailments like hearing loss, incontinence, osteoarthritis and vision loss. These manifestations of decline, neither fatal nor “grievous” on their own, when stacked together, can be framed as irreversible decline with intolerable suffering. Ordinary aging gets repackaged as a terminal medical condition.
The pressure percolates downward. Lemmens’ mother-in-law, a proud Québécoise, initially celebrated Canada’s assisted-dying law as a mark of social progress. “We have this law and we’re so proud of it,” she told him. Years later, after losing her sight and suffering a stroke, the tone changed. When family members spoke casually about acquaintances who had chosen assisted death, she cut them off sharply. “Stop talking about that,” she said. “This is what I’m hearing all the time.” Assisted suicide was no longer a policy option discussed at moments of crisis: It had become a background expectation, present even when no one was asking for it.
While Canada has no specific law allowing euthanasia for “completed life” (a controversial but serious proposal embraced by the ruling political party in the Netherlands), Canada is getting there edgewise. Testifying to Parliament in 2022, psychiatrist and MAID provider Dr. Madeline Li admitted that such cases “have been happening in Canada since even before (the 2021 Track 2 expansion).” Once Track 2 came online, there was no practical limit, she added: “No one reaches older age without some form of qualifying chronic illness.” Canada may in the end not even need to legislate for “completed life.” It may simply diagnose it.
The safeguard question
When I spoke with Baroness Ilora Finlay, she sounded like someone trying to keep her footing on ground already giving way. Finlay is a palliative-care physician and a nonpartisan member of Britain’s upper chamber, the House of Lords. She has spent years inside Britain’s assisted-dying debates, reading bills line by line, proposing safeguards and watching what happens to objections once momentum builds.
In Britain, the Terminally Ill Adults (End of Life) Bill has already passed the House of Commons and now sits before the House of Lords. Under the U.K. system, bills begin in the Commons, where elected MPs debate and vote. The Lords are tasked with revision and scrutiny rather than initiation, and because peers are unelected, their resistance is often framed as obstruction rather than democratic correction.
Finlay has pressed for tighter language, clearer exclusions, stronger protections against coercion. Again and again, she says, the response is the same. Concerns can be handled later, advocates say, through administrative guidance and professional judgment. The bill, she is told, needs only point the way toward limitations. Trust them.
One exchange in particular gnawed at her. During debate, peers warned that end-of-life choices are often shaped by poverty, isolation and lack of care. When pressed on whether the bill would allow poor people to end their lives with assistance because they were poor, the sponsor answered plainly: “I am saying that what the bill does is allow you to make your own decision.” Finlay says she was struck by the clarity of it — an acknowledgment that even when deprivation weighs heavily in the balance, it still counts as autonomy.
Finlay is intently focused on the nuances of pressure. In palliative medicine, she said, death requests surface in moments of pain, panic, exhaustion. Finlay told me of a patient with repeated chest infections who insisted each time that this would be “the last time.” Each time, the patient recovered. And each time became the next time. The meaning of the request, Finlay said, was never to help them die. It was to help them live … this time. “This is why coercion is so difficult to detect,” Finlay said. “You get coercion internally from feeling a burden, and externally from being made to feel one.”
That is why she doubts that safeguards can be reliably enforced. Expansion is rarely driven by zealotry or malice, but by ambiguity, by pressure to resolve hard cases, by the steady normalization of exceptions. Each step is defended as compassionate, she argues, and only later does the cumulative shift come into view. “Once you accept assisted dying as a solution,” Finlay told me, “you stop asking what could have made this person’s life bearable.”
The economics of dying
The cost of care infuses Reid Davenport’s 2025 documentary “Life After.” Davenport, a filmmaker who has cerebral palsy, reexamines the case of Elizabeth Bouvia, a 25-year-old woman with cerebral palsy who, in the early 1980s, sued for the right to starve herself to death in a public hospital. In one disconcerting scene, we see “60 Minutes” host Mike Wallace leaning over Bouvia’s hospital bed intoning: “And what does it cost for Elizabeth’s existence? Nearly $150,000 a year, much of it coming from state- and federally funded agencies.”
“Life After” also tells the story of Michael Hickson, the 46-year-old quadriplegic father of two in Texas who died of Covid-19 after doctors declared his “quality of life” was not worth strong measures. Hickson’s wife recorded the conversations legally but without the doctors’ knowledge. Then there is Michal Kaliszan, a Canadian computer programmer with cerebral palsy whose mother’s death left him without adequate home care, though the Canadian health system readily offered him assisted death. “The government’s solution to my care needs was to put me in a long-term care institution,” Kaliszan tells Davenport. “It feels like it’s an incarceration. In my mind, MAID is the lesser evil.”
It is also the cheaper evil. A 2020 report by the Parliamentary Budget Officer estimated that expanding MAID eligibility would result in a projected net reduction of health care costs for provincial governments of $149 million in 2021. The PBO report was a cost estimate, not a policy recommendation, but the formal savings calculation intensified fears among disabled people that in an overstretched system, death is the ultimate efficiency. For now, Kaliszan was able to piece together an adequate care plan, and he is featured in Davenport’s film as a survivor of the system. But the sword of Damocles still hangs.
When death is available but care is not, choice is no longer neutral.
So what makes a challenging life worth living? On this point, I spoke with Jeff McMahan, a moral philosopher at Oxford University, one of the most influential defenders of assisted dying. Severe disability, he argued, does not by itself make a life unlivable. What matters, he said, is whether a person’s remaining life contains enough goods — meaning, purpose, pleasure and connection — to outweigh its harms.
McMahan cites people at the extreme end of physical limitation whose lives he describes as “very well worth living.” There was Stephen Hawking, of course — a familiar sight at Cambridge University when McMahan was a graduate student there. McMahan also pointed to Tony Judt, a historian, paralyzed by ALS. “He was completely immobile,” McMahan said, “but he was still able to communicate. He collaborated with Timothy Snyder on a book. And his life, even at that stage, was very well worth living.”
There is a term in the disability communities for publicity drawn to the extraordinary lives of a few severely disabled people. They call them “supercrips,” a term that emerged in the 1970s — reclaiming “cripple” with irony. McMahan’s examples of artists and writers are supercrips. They are meant to show that disability does not foreclose a meaningful life. But these stories are legible to outsiders because they still produce recognized value: books, music, ideas. McMahan’s concept of a meaningful life seems to require the judgment of those not living it.
Skeptics are quick to note that McMahan’s reference to Judt’s life as “very well worth living” is an external judgment of a life, not an inner perception of the person living. Dr. Daniel Sulmasy takes that distinction seriously. A physician and bioethicist at the Georgetown University Pellegrino Center for Clinical Bioethics, Sulmasy has spent decades distinguishing what he calls “intrinsic” from “attributed” dignity. Intrinsic dignity comes simply by being human. It cannot be earned, enhanced or lost through incapacity. Attributed dignity rests on status, independence, productivity and social esteem. It is conferred by others, and it can be stripped away by illness, poverty or dependence.
Sulmasy’s worry is about the ordinary cases. The people who cannot point to a visible output that reassures us of their continuing worth. The extraordinary become proof that a hard life can be good, while the ordinary become candidates for triage. Examples offered to defend disabled life end up setting the standard by which other disabled lives are “costed out.” The value gauge migrates from the person living the life to the system judging it.
Valuing difficult lives
While bioethicists and health systems debate how to gauge the value of a difficult life, McKinney knows that the gauge itself can be broken by the disease. What does it mean to choose, McKinney wonders, when the person making the decision cannot imagine a future self who might choose differently?
McKinney is affiliated with the University of Otago’s medical faculty in New Zealand. Her widely cited 2010 thesis, “To Treat or Not to Treat,” reads like a preemptive strike against “terminal anorexia.” In severe cases, she wrote, anorexia becomes linked to identity. For these patients, she argues, the offer of a “cure” represents a demand to abandon the only self they know for a future self they cannot yet imagine. For such a patient to refuse treatment, she writes, is not an expression of autonomy but a symptom of the disease’s colonization of the self.
She’s speaking from experience. For over a decade, McKinney lived with severe anorexia. In September 2002, McKinney, then 28, was in Baltimore doing a postdoctoral fellowship at the National Institutes of Health when her liver began failing. She recalls the ER doctor turning the screen to show her liver enzyme numbers that should have been in the teens, now in the thousands. Without immediate reversal, her prognosis was days, not weeks. But even then, McKinney told me, her anorexic brain resisted. “I remember insisting to the physician arranging my transfer that I was fine,” she said, “even as I could feel myself passing out.”
McKinney’s survival that autumn was due not to willpower, but to people around her who quietly refused to accept the futility of her case. With her in the ER was Dr. Lynn Stansbury, an NIH workplace physician who had noticed the telltale ketosis on McKinney’s breath and urged her to seek help. Stansbury would become a surrogate mother to McKinney, eventually housing her during the most fragile months of recovery.
Foremost in that “found family” was Callum McKenzie, the man who would later become her husband. They had met years earlier at their college graduation, seated alphabetically. By 2002, both were postdocs in Baltimore, and McKenzie became the anchor that held McKinney to the world. “He was my reason for carrying on,” she told me. Only later did she learn that during those months, he would wake at night to check that she was still breathing. Along with colleagues who bent rules and pulled strings to get her into Johns Hopkins, they formed the scaffolding of her survival.
What does it mean to choose, when the person making the decision cannot imagine a future self who might choose differently?
Most people with severe eating disorders never encounter that kind of intervention. They live far from academic centers, cycle through under-resourced programs and exhaust insurance limits. Eventually they may earn the label “severe and enduring,” a phrase widely understood to mean hopeless.
Following her treatment at Johns Hopkins, she and McKenzie returned to New Zealand and married. The physical toll of a decade of starvation remained. Her reproductive system had been effectively destroyed, and she never regained a natural cycle. Yet she found that she “responded beautifully” to fertility drugs. Through IVF, she and McKenzie had two sons, now teenagers — lives that serve as the concrete manifestation of the “future self” she was once incapable of imagining.
McKinney views the trend toward “terminal” psychiatric diagnoses with the precision of a pathologist and the wariness of a survivor. “The idea of a ‘terminal mental illness’ is just a way of sanitizing it,” she told me. “It makes it easier for people to accept that we are getting rid of the most vulnerable.”
Two physicians disagree
As New York state moved to legalize assisted death in 2025, the debate was embodied by a pair of upstate New York colleagues who spent their careers together making death gentler. Dr. Robert Milch was a surgeon and a pioneer of palliative medicine who cofounded Hospice Buffalo in 1978. For decades, he worked alongside Dr. Christopher Kerr, his colleague, who is the hospice’s current CEO and chief medical officer. Kerr describes Milch as his “mentor and dearest friend,” a man with whom he built a legacy of care. “This is the one issue we never saw the same way,” Kerr told me.
Milch became a fierce advocate for medically assisted death. In testimony to the New York Legislature and op-eds written days before his own death from cancer in 2021, Milch argued that for some, the ravages of disease demand only endurance, serving no useful or meaningful purpose. The state should not dictate how much a person must bear. Milch viewed the denial of the right to die as “inexcusable paternalism.”
Kerr sees a different paternalism in hastening death: the presumption to know that the final act can be hurried without loss. Over a decade of published research, Kerr has tracked the vivid dreams and visions that often flood the final weeks of life. These experiences are structured, “more real than real,” and almost universally focused on reconciliation, often centered on the return of deceased loved ones.
Where Milch saw futility in dying, Kerr’s data revealed a process of spiritual and psychological resolution. Using standardized scales, Kerr found that dying patients scored “enormously high” in measures of post-traumatic growth. Many appear to use their final days to revisit trauma, repair relationships and reckon with past experiences. Memories return. Figures from the past reappear. Conversations resume. This internal work requires time that may be shortchanged by fears of future suffering — often as projected by the healthy, rather than experienced by the dying.
For patients whose lives were jagged and unresolved, the experiences often involve hard healing. Kerr tells of a retired police officer whose life had been marked by cruelty and moral wreckage. As death approached, the man’s dreams began circling the same memories again and again, often in traumatic form. “People die as they live,” he told me. But in the case of the police officer, as in others like it, Kerr noted, surprising peace and resolution did come as death neared. The work was not always pretty, but it was real. And it was happening to the very end.
These themes likely do not surprise those steeped in traditional cultures. In Jewish tradition, a person in the last stage of life is likened to a flickering candle, and the moments before death are a time for moral repair and reconciliation. Tibetan Buddhism calls the dying interval itself the bardo of the moment of death — a narrow window in which consciousness may recognize the “clear light” and achieve liberation. Hindu traditions likewise treat the moment of death as spiritually consequential, emphasizing disciplined attention and remembrance at the final breath as key for a soul’s passage beyond the body. Divergent traditions converge on the notion that the liminal space before death is a time of gathering, reconciliation and transition.
Kerr scrupulously declines to interpret the source or purpose. Readers have to decide whether to cast them in guises ranging from biological to religious, Buddhist to Christian. “I have no clue,” Kerr told me. “I just know it’s theirs.”
There is, however, good evidence that these experiences are not shaped by prior religious beliefs. A Swedish qualitative study set out to test just that question. Conducted in one of the world’s most secular societies, the study found that 16 of 25 patients in palliative end-of-life care reported end-of-life experiences. The most common elements were encounters with loved ones — both living and deceased — and imagery of travel or transition.
Parallel findings appear in the work of neuropsychiatrist Peter Fenwick in the United Kingdom and palliative care researcher Michael Barbato in Australia. Fenwick documented similar phenomena in British palliative settings, including nursing homes and hospice care, where patients reported coherent experiences involving journeys, reunions or reassuring presences. Barbato’s research in Australian palliative care units likewise described near-death experiences that patients experienced as structured and emotionally significant.
A recurrent theme is that those experiencing death rarely fear it. “There’s the dying that people imagine and then the dying that occurs,” Kerr said. He described a recent meeting with hospice colleagues representing a combined 160 years of bedside experience. “You would think that if anyone were to see requests for a hastened death, it would be us,” he said. Yet when the question was raised, he said, no one in the room had ever heard that request. The reason, Kerr says, is that pain is well managed in palliative care. “The reality is there isn’t a symptom we can’t manage,” he said.
Kerr’s claim here is well documented. According to a 2021 Oregon study, pain does not even reach the top five reasons for choosing assisted death. Over 90 percent cite the loss of autonomy and the ability to engage in enjoyable activities. Over 70 percent cite loss of dignity. Only 27 percent cite “inadequate pain control or concern about it,” a category that notably includes those anticipating pain they have not experienced. In short, the primary drivers of assisted dying are not medical symptoms but existential distress and the social terror of dependence.
Writing as he faced his own end, Milch insisted that symptom management is not the whole story. He acknowledged that palliative care succeeds “more often than we failed, but not always, not for everyone.” For Milch, the issue was not just pain scores, but the patient’s own definition of meaning. He argued that even if a doctor can manage the physical pain, they cannot judge the existential cost of disintegration. To force a patient to endure a life they deem pointless, solely because a doctor believes they can “manage” it, was, in Milch’s view, a breach of “humane decency.”
Kerr, in turn, sees Milch’s proposed solution as a sterile, technological substitute for a profound human experience. He views the rush to an exit ramp as a modern version of the “doctor’s death” — designed to control an experience that is meant to be surrendered to. “It’s a technological obsession and arrogance that doesn’t stop,” Kerr told me.
As lawmakers across Europe and the Anglosphere debate expanded access to assisted death, most advocates, having dropped the pain argument, now instead focus on “autonomy” and “subjective suffering.” But if Kerr is right, the systems we are building to liberate us may deprive us of the final, necessary work of being human. “There is more grace baked into the natural dying process without our involvement,” he said, “if we just got out of the way.”
This story appears in the April 2026 issue of Deseret Magazine. Learn more about how to subscribe.