There has been extensive debate on assisted suicide and euthanasia in westernised countries during the last twenty years. At the same time, we have seen an increase in the acceptance of assisted suicide and euthanasia (hereafter: “assisted dying” to cover both phenomena) among the general public in most western European countries.1 In several of them, corresponding political attempts have been made to change the penal code.2–5 Such attempts have succeeded in The Netherlands and Belgium.67 An open practice of assisted suicide has developed in Switzerland over the last two decades, based on the non-penalisation of unselfish assistance with suicide that exists under Swiss law.3
The medical profession has traditionally maintained a clear distance from euthanasia and assisted suicide. However, since there is active debate in many European countries, and proposed or even enacted legislation in some places, it has become increasingly difficult to justify such distance by simply referring to the law or to common sense arguments against any assistance in dying. It does not make it any easier for doctors that discussions in the media, courts, and legislatures often assume assistance in dying to be exclusively a physician’s task.5–7 In order to avoid being overtaken by possible political developments, doctors are challenged to either give specific reasons why they should not be involved, or work out the role they could conceivably play if need be.
This paper analyses legislation and, in particular, medical professional positions on the doctor’s role in assisted dying in certain Western European countries. It follows their development and discusses the implications for the doctors themselves.
To provide an overview of the possible positions in the field, an approach taking ”country” as the entity for comparison was considered appropriate. Not only legal regulations, but also medical ethical positions seem to develop in ways that are highly country-specific. The country is still the most important predictor of doctors’ attitudes and practices in the field of end-of-life decisions in Europe.8
We included countries where assisted dying has been legalised or is openly practiced (Belgium, The Netherlands, Switzerland), and countries where it remains illegal or otherwise banned from practice (Germany, Norway, the United Kingdom). An expert in the field of assisted dying familiar with both the legal situation and the medical professional position from each country was invited to join the research team. These representatives do not necessarily agree on whether assisted dying should be allowed or on the possible role of doctors.
Each participant was asked the following key questions:
Is assisted suicide and/or euthanasia unpunished/legal in your country, or is there any attempt to make it unpunished/legal? What is the (envisaged) role of the doctor in this (proposed) law?
What is the official position of the medical profession on assisted dying and on a possible role of doctors in these practices? Has this position changed in any way in recent years?
In this study, the term “assisted dying” includes both euthanasia and assisted suicide; in keeping with common usage, “euthanasia” means only voluntary euthanasia.9
Legal situation with regard to assisted dying (table 1)
Although euthanasia and assisted suicide were illegal in The Netherlands until recently (articles 293 and 294 of the Dutch penal code), both practices were tolerated by the courts from the early 1970s. The Netherlands eventually became the first country in Europe to formally depenalise assisted dying by a law (Review Procedure Act) that came into force in April 2002.6 Belgium, where no relevant case law and no established or regulated euthanasia practice similar to that of The Netherlands existed, followed suit in September 2002, after having enacted a euthanasia law in May the same year.7
In Switzerland, assisted suicide (but not euthanasia) is not illegal according to the 1918 penal code, provided assistance is given without any motives of self-interest.3 The legal situation is similar in Germany where assisted suicide (but not euthanasia) is not illegal in principle.2 However, unlike in Switzerland, in Germany assisted suicide may legally conflict with a doctor’s or a relative’s obligation to save life. Both euthanasia and assisted suicide are prohibited under the Norwegian Penal Code (articles 235 and 236) dating back to 1902.4 The same holds true for the UK where even suicide was a crime in England and Wales until 1961.5 The Suicide Act then decriminalised suicide but retained the criminal prohibition of aiding and abetting.
Group targeted as assistants in dying by legislation or proposed bills (table 2)
Both the Dutch Review Procedures Act and the Belgian Euthanasia Law are restricted to doctors by exempting these professionals from penal liability for assistance in dying, provided certain criteria of due care are met.67
The non-penalisation of assisted suicide in the German and Swiss Penal Codes differs in that it applies to everyone, be they doctors or not. In 2001, the Swiss Federal Parliament confirmed both the current legal situation and the activities of Swiss right-to-die societies, in which both doctors and non-physicians participate in suicide assistance.3 In Germany, a group of legal experts recently proposed that doctors assisting patients in suicide should not be censured or prosecuted, which in fact would mean that the legal situation with respect to assisted suicide would become similar to that in Switzerland, both in general and for doctors in particular.2
The most important attempt in the UK to change the legal situation, the Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 and rejected by the House of Lords in 2006, focused on doctors.510 In contrast, the 2002 minority Proposal on Assisted Dying of the Norwegian Penal Code Commission– turned down by the Norwegian Parliament in an unanimous vote in May 2005– made no specific mention of doctors but proposed a requirement that the patient be “terminally ill”.4
Medical professional positions (table 3)
The Royal Dutch Medical Association played a key role in developing the Dutch euthanasia model from the very beginning, without expressing any major concerns as to the compatibility of this practice with medical professional ethics.611 Allowing a role for non-doctors was hardly ever seriously considered. An inquiry commissioned by the Royal Dutch Medical Association recently concluded that individuals with no illness at all could also qualify for assistance in dying, and that even in these cases doctors should be the only ones to decide whether the “suffering through living” is great enough.12
In contrast, the Belgian National Council of Physicians found it difficult to establish an adequate position when confronted with the rapid and radical legal changes in the field of euthanasia in Belgium in the early 2000s. The reality of the new Belgian law was finally accepted in an Advice of March 2003.13 Art. 95 of the Code of Medical Deontology, which previously prohibited doctors from providing any assistance in dying, was changed only in March 2006.14 In the revised Art. 95–98, the Code now mentions the duty of the physician, on receiving a question regarding the end of life, to inform the patient of the initiatives that the latter can take (including writing a living will covering euthanasia) and includes a somewhat ambiguous statement that a doctor should provide any medical and moral assistance required.
The Swiss Academy of Medical Sciences took a different route towards adopting a “neutral” stance. The Academy maintains the basic incompatibility of assisted dying with the role of the doctor, but today respects assistance in suicide as the doctor’s personal decision in the individual case.15
Medical associations in Germany, Norway and the UK continue to strongly condemn assisted dying in any form.51617 In the UK however, the fact that both the British Medical Association and the Royal College of Physicians of London for a time adopted a neutral position to the Assisted Dying for the Terminally Ill Bill, but later backtracked and again took a stance against legislation, shows how controversial the subject is, even amongst doctors in this country.1819
More details on the legislation and medical professional positions and their development in the various countries, including additional references, can be found online..
Doctors between resistance and acquiescence
Faced with increasing public acceptance of assisted dying in Europe, corresponding attempts to change the penal code, and actual changes of the law in some countries, the medical profession mostly strives to prevent or to slow down the process. What is occurring may be described as a power struggle: society wants the option of physician-assisted death to be available, while the overwhelming majority of medical organisations continue to view such assistance as incompatible with their codes of professional ethics. Even so, there is no unanimity within the medical profession.20 Those specialists who are most likely to be entrusted with assisting in death (eg oncologists, palliative care doctors) are those who oppose the legalisation of assisted dying most strongly. In other words, the conflict is essentially between those who want the option of assisted dying to be available, and those who would be responsible for implementing it.2122
So far, doctors have been able to prevent any opening up in Germany, Norway, and the UK. Nevertheless, the campaign debate for the Assisted Dying for the Terminally Ill Bill in the UK was powerful enough to cause the British Medical Association and the Royal College of Physicians of London to waive their opposition for a while.1819 And at the moment there is considerable pressure on the German Medical Association arising from the proposal of a group of legal experts that doctors assisting patients in suicide should neither be prosecuted under criminal law nor censured by medical professional ethics.2
In the last few years, Swiss and Belgian doctors gradually acquiesced in what had already been legally condoned or established as a new legislation in a democratic process, respectively. The process of acquiescence is particularly impressive in Belgium, where legal changes made in direct opposition to the official medical ethical position presented the medical profession with a fait accompli. The Belgian National Council could do nothing more than state: “When in a democratic state a law [on ethical issues] is established and this law respects the freedom of conscience of each physician, the existence of this law cannot be ignored by a public institution such as the Order of Physicians.”13 In Switzerland, too, the Swiss Academy of Medical Sciences was forced to moderate its statement that “assistance in suicide is not a part of a doctor’s activity” so that assistance in suicide in individual cases now has to be respected as the doctor’s personal decision.14
Only in The Netherlands do we find almost complete symmetry between what the law conceives as the medical profession’s role in assisted dying and the official view of the profession itself. However, evidence from The Netherlands suggests a continuing unwillingness of doctors to report cases of such assistance to the authorities, and a return to practices such as terminal sedation that are accepted as normal medical practice and do not need to be reported to the authorities.23
Keeping out or being the experts?
Open regulation of assisted dying brings doctors into a basic conflict. On the one hand, many doctors do not wish to have anything to do with a practice that they regard as incompatible with professional ethics. On the other hand, once opening up seems inevitable, they want to introduce the safeguards they deem necessary. The more they get involved in these discussions, however, the more they are drawn, albeit unwillingly, into the role of experts in a field that extends far beyond medicine. Utilisation of that exclusive expertise is exactly what is presupposed in much legislation and proposed bills.5–7
Should this role be taken on without modification by the medical profession, it would lead in the direction of the Dutch model where euthanasia and assisted suicide have been socialised within the medical profession as just another “medical end-of-life decision”.24 However, such a role for the medical profession seems particularly inappropriate if, as has happened in The Netherlands, the indications for assisted dying are progressively extended.12 Requests to die in cases of “suffering through living” can be seen either as a strictly personal matter or as a social issue, that is, something that society has a duty to deal with. But as these individuals do not suffer from any medical condition at all, or at least not from any severe illness, it is difficult to justify the view that their plight is a medical matter. There is hardly any argument why doctors should have more expertise in such cases than other professionals.
However, it has been suggested that open regulation of assisted dying could also be implemented by establishing a suicide service outside clinical care, run by a designated interdisciplinary team.25 This model, in which non-penalisation of assistance in dying would be restricted to these specialised services rather than to any one profession, could ensure competent assessment of the person wanting to die according to standard regulations agreed on by the public through a political process. Any role conflict for clinicians faced with a patient’s request for assistance in dying would thereby be avoided, as their role would be clearly confined to openly discussing the situation, indicating possible treatment or palliative care options, and offering further support in this respect. Nevertheless, no state has yet shown great interest in engaging in a field in which it is extremely difficult to establish appropriate decision criteria but, at the same time, any wrong decision has far-reaching and irreversible consequences.
An interdisciplinary approach?
Against the background of our analysis, it is apparent that, if society is willing to make assisted death an available option, the responsibility for such decisions must be spread as widely as possible, that is, borne by society as a whole.25 It is not enough that the law and ethical guidelines lay down limits for doctors who assist in dying and that the observance of these conditions is monitored by lawyers and– as is the case in The Netherlands– ethicists. Much rather, these two groups, together with other professionals such as clergy, nurses, pharmacists, social workers, and any “lay people” who have sufficient experience of life, should be prepared to bear joint responsibility for specific cases, for example when a particularly difficult decision has to be taken. Whether or not a state-run service for assisted dying, as outlined above,25 is the most appropriate instrument is another question altogether, as this might be too bureaucratic and impersonal to meet the expectations and needs of the individuals wanting to die and their families.
What doctors can do at this stage is to identify where medical expertise is essential in this field and to define those questions to which medical knowledge provides no answer. Given the fact that most professional medical organisations decline even to consider the subject at the present time, official positions of doctors in this field are scarce. However, a Consensus Panel of the University of Pennsylvania Center for Bioethics, Pennsylvania, USA, succeeded in bringing together a number of acknowledged experts in this field.26 The panel identified communication of information about diagnosis, prognosis, and the full range of treatment options as clearly within the doctor’s expertise. Concomitant factors such as depression would, of necessity, have to be assessed by a doctor. According to the panel, tasks such as addressing questions of coercion, spiritual issues, and even symptom control, are often better performed by nurses, social workers, and clergy or other spiritual advisors. These experts also raised the question whether it would be better to assign a non-physician to coordinate and supervise the overall process.
Interestingly, these suggestions, although developed independently in a different cultural and health-care context, correspond closely with the position of the Swiss Academy of Medical Sciences on assisted suicide, as outlined in their medical-ethical guidelines on the care of patients at the end of life.15 According to the Swiss Academy of Medical Sciences, exclusively medical tasks are to establish that the patient is approaching the end of life, to discuss the medical condition and its consequences and, if desired, to implement alternative options for treatment and palliative care. On the other hand, ascertaining that the patient is capable of making the decision and that the wish to end life is well-considered, persistent, and arrived at without external pressure is not exclusively a medical task– for this reason, the person providing a second opinion on these points must not necessarily be a doctor.
Against the background of increasing public acceptance of assisted dying in Europe, the fundamental question of the appropriate role for doctors in an area that goes beyond medicine remains contentious. A society striving for an open approach towards assisted dying should carefully identify the tasks that should be assigned exclusively to medical doctors and separate out those that might be better performed by other professions.
GB and BG thank the teams of both the Centre for the Economic and Social Aspects of Genomics (GESAGen) and of the International Observatory on End of Life Care (IOELC) at Lancaster University for their outstanding hospitality and friendship.
All authors are indebted to Dr Mergl Clarke for translating parts of the text into English and for critically revising the whole manuscript.
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Current law regarding assisted suicide
The practice of assisted suicide in Switzerland has led many people to believe that the practice has been legalized in that country. That is not the case. There is an important distinction between the Swiss situation and that of Oregon, the Netherlands and Belgium where the law considers euthanasia and/or assisted suicide to be “medical treatment.”
According to Swiss law, “Whoever, from selfish motives, induces another to commit suicide or assists him therein shall be punished, if the suicide was successful or attempted, by confinement in a penitentiary for not more than five years or by imprisonment.”
Source: Article 115 of the Penal Code of Switzerland (emphasis added).
The key words are “from selfish motives.” Thus, in Switzerland, there is no prosecution if the person assisting a suicide successfully claims that he is acting unselfishly. While this results in de facto legalization, assisted suicide is not legal, only unpunishable, unless a selfish motive is proven. It should also be noted that there is no illusion that assisted suicide is a medical practice. The person assisting a suicide need not be a medical professional to escape prosecution.
“Switzerland’s ‘peculiar institution'”
(BioEdge — June 4, 2013)
What is the position of the law on assisted suicide in Switzerland? Journalists often make the mistake of asserting that euthanasia is allowed there. This is not true: only assisted suicide — but this has been legal, astonishingly, since the 1930’s.
LAW EXPANDED TO REQUIRE HEALTH FACILITIES TO PERMIT ASSISTED SUICIDE
On June 17, 2012, sixty-two percent of voters in the French-speaking Canton of Vaud approved a law that requires nursing homes and hospitals, called Socio-medical Establishments (SME’s) to permit assisted suicide in their facilities.
The initiative requested that the Swiss Law on Public Health of May 29, 1985 be amended as follows:
“The introduction of an Article 71 (b) entitled ‘Assisted suicide in SMEs’ with the following text: ‘SMEs in receipt of public subsidies must allow assistance for suicide to be provided in their establishments for any resident who makes a request to this effect to an association supporting the right to die with dignity or to the doctor responsible for his or her treatment, in accordance with Article 115 of the Swiss Criminal Code and Article 34 (2) of the Constitution of the Canton of Vaud.” (emphasis added)
Alda Gross, a Swiss citizen, has filed a lawsuit in the European Court of Human Rights to force the government of Switzerland to ensure her right to obtain lethal drugs to end her life. Gross, who has no known pathological condition contends that she has the right to assisted suicide because she’s frail and has no desire to continue life.
The European Court of Human Rights impacts 47 countries making the outcome of importance throughout Europe.
On March 20, 2012, the Alliance Defense Fund, an American legal advocacy organization, filed as a Third Party Intervener brief in the case.
(National Review — January 16, 2018)
Switzerland has amended its constitution to recognize the individual dignity of plants…[I]t is immoral to “decapitate” a wildflower….[However] Switzerland allows “suicide tourism” through which locals and foreigners attend suicide clinics that charge thousands of dollars to make their clients dead — including joint suicides of elderly couples and an Italian elderly woman despairing over lost looks.
“Zurich doctor fined for not reporting assisted suicide”
(Swiss Info — April 11, 2016)
Swiss law tolerates assisted suicide when patients commit the act themselves and helpers have no vested interest in their death….Death is usually induced through a lethal dose of barbiturates that has been prescribed by a doctor. Ingestion of the poison, whether by drinking it or through the use of intravenous drips or stomach tubes must be carried out by the person wanting to die.
More on drugs used for assisted suicide
“Healthy retired nurse ends her life because old age ‘is awful'”
(Telegraph — August 2, 2015)
Gill Pharaoh, 75 years old, traveled to Switzerland to die at a suicide clinic. “The thought that I may need help from my children appalls me,” she said. I” know many old people expect, and even demand, help from their children but I think this is a most selfish and unreasonable view.”
“Swiss Right-to-Die Group Gets Green Light for New Suicide Room”
(NDTV — July 6, 2015)
Exit, which provides lethal drugs to help people die, said the Basel canton’s local building council had dismissed objections to its plan to convert part of its office in Binning, Switzerland into an assisted suicide room….In 2011, voters in the canton of Zurich rejected a proposed ban on assisted suicide and “suicide tourism.” A year later, the national parliament voted against tightening controls on the practice.
“The ethics of new organ donation methods”
(Swiss Info — December 14, 2014)
Is it ethical to use organs from people who have died with assisted suicide? Biomedical ethicist David Shaw [of the Institute for Biomedical Ethics at the University of Basil] believes it’s one of the ways to try and counter organ donor shortages.
More on Organ Donation
“Swiss suicide clinic helped SECOND woman ‘tired of life’ to die”
(Express — UK — April 13, 2014)
The 99-year-old, who was not terminally ill or severely disabled, felt her time had come to an end.
“Teacher died at Dignitas because she couldn’t bear modern life”
(Daily Mail — April 7, 2014)
The 89-year-old, from Sussex, said she couldn’t keep up with modern life. She claimed new technology had ruined face-to-face human relationships. She was neither terminally ill nor disabled, but ended life at Swiss Clinic.
“Analysis of legal assisted suicide in Switzerland”
(BioEdge — March 8, 2014)
The right-to-die associations are not following the law, but the authorities do not seem to be reacting…. Nowadays, Swiss assisted suicide is “marketed” as a remedy for an unendurable disability….
“Healthy people are traveling abroad for assisted suicide because they grow ‘weary of life'”
(Mirror — UK — February 20, 2014)
Around 16 percent of the people who use ‘right-to-die-organizations such as Dignitas have no underlying health problems listed on their death certificates…Loneliness and feeling unloved are twice as likely to kill you as being fat.
“Italian woman, 85, ends her life at Swiss euthanasia clinic because she was upset about losing her looks”
(Daily Mail — February 20, 2014)
Oriella Caszzenello was healthy. She disappeared without telling her relatives where she was going. Her family, who had reported her missing, learned of her death after they received her ashes and death certificate from the clinic.
“Aided suicide in question after botched diagnosis”
(The Local — Switzerland — July 11, 2013)
A 62-year-old Italian magistrate was not gravely ill as he was told before he went to Switzerland for an assisted suicide. An autopsy carried out by the University of Basel’s Institute of Forensic Medicine found that Pietro D’Amico was not suffering from a life-threatening illness at the time of his death.
“Coming Swiss Suicide Right for the Healthy?”
(National Review — May 26, 2013)
In Switzerland, a healthy woman who didn’t want to experience the decline of aging but was actually denied assisted suicide, has sued, claiming a doctor should be forced to prescribe for her. The court didn’t do that, but has ordered the country to create more clarity in its law about who has the legal right with help being made dead.
“EU court finds Swiss assisted-suicide laws vague”
(WAVY — May 22, 2013)
The Strasbourg, France-based court said Switzerland must specify whether its laws are meant to include people not suffering from terminal illnesses and, if so, spell out the conditions under which they can end their lives.
“Nurse traveled to Switzerland to end life in Dignitas clinic”
(Birmingham Mail — April 3, 2013)
Unable to swallow because of her debilitating illness, Diane Whittle consumed a large amount of pentobarbital, a lethal and short-acting barbiturate, by passing it through a feeding tube in her stomach.
“Significant stress after witnessing assisted suicide”
(BioEdge — October 6, 2012)
Relatives and friends of a person who commits assisted suicide have a high rate of post-traumatic stress disorder and depression, according to a Swiss study in he latest issue of European Psychiatry. “Witnessing the unnatural death of a significant person thus seems to have a strong impact on the bereaved, which may lead to severe mental health problems at 14 to 24 months post-loss.”
“Swiss parliament rejects tighter controls on suicide”
(Reuters — September 26, 2012)
Switzerland’s parliament voted against a bid to toughen controls on assisted suicide on Wednesday, rejecting concerns about foreigners traveling to the country to die….The number of Swiss residents who died by assisted suicide rose sevenfold between 1998 and 2009, according to official statistics, with almost 300 Swiss residents dying this way in 2009, compared to 43 in 1998.
“Vaud to get first Swiss assisted suicide law”
(Swiss News World Wide — June 17, 2012)
On June 17, 2012, the Swiss canton of Vaud voted in favour of a proposal obliging nursing homes and hospitals to accept the practice of assisted suicide in their facilities. Exit, the pro-assisted suicide advocacy organization, estimates that 50 percent of the 1,600 old people’s and nursing homes in the German-speaking part of the country already allow assisted suicide under their roofs — up from 20 percent five years ago.
“More nursing homes allow assisted suicide”
(The Local — June 13, 2012)
In a recent poll of nursing home employees in the German-speaking part of Switzerland, more that 50 percent confirmed that assisted suicide was practised at their place of work; newspaper Tribune de Genève reported.
“Swiss canton to vote on assisted suicide”
(The Local — June 1, 2012)
The people of the canton of Vaud will vote on June 17 to decide whether to require nursing homes and hospitals to accept assisted suicide on their premises.
“World-weary Swiss seniors seek suicide help”
(The Local — May 9, 2012)
New figures show that more and more Swiss seniors are taking advantage of assisted suicide even when they do not suffer from any terminal diseases.
“Swiss see steady rise in assisted suicides“
(Associated Press — March 27, 2012)
Five out of every 1,000 deaths in Switzerland now involve assisted suicide, with women more likely to die this way than men, according to the first official figures released Tuesday.
“Case puts assisted suicide at crossroads”
( Swiss Info – – January 4, 2011 )
A regional criminal court in Boudry, canton Neuchatel, ruled that a doctor had no choice when she took the final step to end the life of a terminally ill patient….The court ruled that as there was no doubt about the patient’s wishes, the doctor in this case had a medical and moral duty to break the law out of compassion.
“Let the distraught partners of terminally ill who commit suicide die too, says Dignitas boss”
( Daily Mail – – October 19, 2010 )
Ludwig Minelli, the founder of the controversial Swiss clinic Dignitas, has said a person whose terminally ill partner commits suicide should also be given help to die – even if perfectly healthy. It is not the first time Minelli has argued health people should be given the legal right to die. Last year he said that he believed assisted suicide should be available ‘on demand.’
“Dignitas boss: Healthy should have right to die”
( BBC – – July 2, 2010 )
Ludwig Minelli, founder of Switzerland’s assisted-suicide clinic (Dignitas), says his death clinic services are available to anyone. Asked if he would assist in the suicides of people who are neither physically nor mentally ill, he said, “Of course… Why should we say no?”
“Dignitas founder is millionaire”
(Telegraph – – June 24, 2010)
Ludwig Minelli, the Swiss founder of Dignitas, has become a millionaire in the ten years since he set up his controversial suicide clinic.
“Swiss suicide clinic Dignitas probed after patient suffering from paranoid schizophrenia was given suicide kit”
( Daily Mail – – June 1, 2010 )
Mentally ill woman given suicide kit in Switzerland. Dignitas suicide clinic founder Ludwig Minelli defended the action, saying: “Every person in Europe has the right to choose to die, even if they are not terminally ill.”
“Ashes of 50 Britons dumped in lake”
( The Sunday Times – – May 9, 2010 )
The remains of up to 50 Britons who ended their lives at a controversial Swiss suicide clinic have been dumped in a lake, according to a nurse who worked at the organization.
“Death Becomes Him”
( The Atlantic – – March 1, 2010 )
Over the past decade, Ludwig Minelli has helped more than 1,000 people kill themselves and has turned Zurich into the undisputed world capital of assisted suicide.
“Cashing in on despair?”
( Daily Mail – January 25, 2009 )
The black plastic bin liners were bulging and cluttered the back stairs to the office of Ludwig Minelli, founder and head of the assisted suicide organisation Dignitas. Soraya Wernli was new to the job as a ‘companion’, one of those hired by Minelli, 75, to assist people in their final journey to the ‘other side’.