When Nelson Mandela died in December 2013 he lived six months longer than he should have. Doctors overzealously extended his life through aggressive interventions, most likely on political instruction.
Critics asked: are they honouring a hero or prolonging unbearable suffering?
Mandela’s close friend, Anglican Archbishop and Nobel laureate Desmond Tutu, was in no doubt. There was no honouring of a hero, just a “disgraceful affront” to Madiba’s dignity.
“The Arch”, as Tutu was affectionately known, vocally supported dignity in death. He also supported one of medicine’s most explosive and enduring ethical dilemmas — assisted dying (AD).
The debate around AD is global, rancorous and contentious. It has “wonderful people on each side holding strong opposing views”, says Prof JP van Niekerk, University of Cape Town emeritus professor and former dean of the health sciences faculty. Van Niekerk favours legalising AD.
It leaves a question hanging in the ether: are doctors who practise AD healers or killers?
Currently, 15 countries allow some form of AD. None is on the African continent. That’s apart from some stirrings in Kenya, which has basically adopted SA’s constitution.
SA, with its progressive constitution, is poised to lead the continent. But only if it successfully navigates powerful, opposing forces in this moral medical minefield.
On one side is Doctors for Life International (DFL), founded in 1991. It’s a faith-based Judeo-Christian group, opposed to AD as a contravention of medical ethics. It advocates for protecting “the sanctity of life from fertilisation until natural death”.
The sanctity of life is a religious and ethical doctrine that assigns supreme inherent value to human life.
On the other side, DignitySA, a nonprofit group of academics, bioethicists and medical doctors founded in 2011, advocates for AD as a constitutional right, based on the right to life.
The right to life is also an entrenched religious and ethical doctrine.
DignitySA wants access for adults to the full range of end-of-life care options with their choices respected and legally protected. In January 2023, DignitySA began preparing an application to the high court in Pretoria on two counts:
- To have the general common-law prohibition of medically assisted dying declared unconstitutional and invalid, thus decriminalising it in light of constitutional rights.
- To advise parliament to write law legalising and regulating AD.
The group hopes to submit all court papers by June 2025. The application leverages evidence from local case studies, 14 foreign experts and multiple SA medical professionals. Constitutional rights underpinning it are:
- The right to respect for and protection of human dignity (article 10), intertwined with the right to life (not merely biological life, but life with a certain physical and mental quality).
- The right to freedom and security of the person, including the right not to be treated or punished in a cruel, inhuman or degrading way (article 12(1)).
- The right to bodily and psychological integrity, including the right to security in and control over one’s body (article 12(2).
The case is expected to go through the Supreme Court of Appeal and Constitutional Court. DFL is girding its loins for legal battle by mustering forces. These may include palliative-care physicians, the health department, the Health Professions Council of SA and foreign experts.
Controversy around AD is as old as the hills of ancient Greece. It is rooted in philosophy and ethics in law, medicine and framing of life and death. It turns terminology into a semantic battleground, with euthanasia and suicide at the helm and euphemisms softening or sharpening moral implications.
Euthanasia is broadly defined as the deliberate act of ending a person’s life to relieve suffering, typically by a physician administering a lethal substance.
AD has two “doctor-assisted” forms, hence the term, “assisted dying”. It is either “patient-administered” (formerly assisted “suicide”) or “doctor-administered” (formerly voluntary “euthanasia”).
“Assisted” refers to a doctor sourcing and supplying the means to cause death. “Administer” refers to application of the means, for example, ingesting a substance (patient-administered) or lethal injection (doctor-administered).
The distinction in who performs the final act is significant in law, ethics and public debate. In SA and elsewhere, euthanasia and AD remain illegal. The terms are treated differently in legislation and public policy debates.
Switzerland introduced AD in 1942 through article 115 of its Swiss Penal Code (enacted in 1937), calling it “assisted suicide”. It mandates individuals to self-administer a lethal drug according to legal, procedural guidelines. No terminal illness diagnosis is required.
Later guidelines suggested prioritising those “approaching the end of life”. Guidelines in 2024 recommend two physician consultations two weeks apart, except in urgent cases.
The Netherlands legalised assisted suicide in 2002, later extending it to minors aged 12 and above, including for mental illness. Belgium followed in 2002, becoming the only country that combines palliative care with an AD option.
Canada’s “medical assistance in dying” (MAiD) legislation, introduced in 2019 is among the most progressive globally. Its permissiveness is contested and evolving. It includes voluntary active euthanasia and assisted suicide, reflecting how boundaries blur depending on jurisdiction.
DFL founder and CEO Albertus van Eeden says that despite perceptions, his group’s arguments are grounded in “science, medical ethics, compassion and concern for vulnerable populations”, not religious conviction.
“It’s amazing to what degree science actually supports Judeo-Christian ethics,” Van Eeden says. “As doctors, we are trained and inherently committed to preserving and saving life. It is ingrained in our genes.”
AD is a euphemism for the “harsher reality of assisted suicide”, he says. Assisted suicide requests are often “cries for help”. Doctors’ ethical duty is “compassion and affirmation of life, not active involvement in helping patients die”.
DFL’s arguments against AD dying are two-fold: suicide contagion and “slippery slopes”, with coercion wedged in between. Suicide contagion is well-documented in ancient and modern medical literature, Van Eeden says. It shows that “exposure to suicide can lead to more suicides”.
The AD lobby dislikes the slippery-slope argument “because it is a strong one”, supported by historical precedents during Nazi Germany. Van Eeden cites an article in the New England Journal of Medicine in July 1949 by Dr Leo Alexander, a medical investigator at the Nuremberg Trials.
Alexander examined the German medical profession’s complicity in Nazi atrocities. He detailed small, seemingly benign shifts in medical ethics, including the notion of “life unworthy to be lived”. These led to systematic euthanasia of the disabled, unethical human experimentation and finally, genocide.
“This progression underscores the dangers of eroding ethical standards in medicine and subjective criteria for assisted suicide,” Van Eeden says.
The Netherlands is a “prime example”. Since 2001, it has extended AD to minors (aged 12 and up and not always with parental permission), and those with mental health conditions. That’s based on the argument that mental suffering can be as unbearable as physical pain.
“Yet most psychiatric conditions are treatable,” Van Eeden says. “And we live in a time of the best pain management in mankind’s history.”
Borderline cases where doctors can terminate or withhold treatment to hasten a patient’s end should be “the exception, not the rule”, he says. There’s a “critical, ethical difference” between a doctor who kills a patient and one who allows a patient to die.
The doctor is the active agent in killing, “effectively playing God”. This contravenes medical ethics. In allowing death, the disease is the “active agent that kills”. The doctor’s attitude is one of “humility, compassion and resignation in stepping back”.
Coercion of vulnerable population groups is a “real phenomenon” that can be “too subtle for the law alone to control and prevent it.”
Death with dignity is “best upheld through compassionate care and support, enshrined in ubuntu ... not through euthanasia”, Van Eeden says.
DignitySA was founded in 2011 by Prof Sean Davison, a biomedical scientist and right-to-die activist, and Prof Willem Landman.
Landman is professor extraordinaire in philosophy at the University of Stellenbosch. He holds degrees in philosophy, political philosophy, theology and law from Stellenbosch, Oxford and Unisa. He was professor of medical ethics at the University of North Carolina in the US before becoming founding CEO of The Ethics Institute in SA.
DignitySA uses assisted dying instead of euthanasia and assisted suicide to avoid stigmatising associations with historical, cultural connotations of irrationality, moral failing or criminality.
“There’s nothing compassionate or rational in compelling people to continue living when only death can free them from intractable, unbearable suffering,” Landman says.
AD is about “voluntary death, respect for autonomy, compassion and fellow-feeling”. It emphasises patient autonomy and compassionate end-of-life care, framing the act as a “medically supported choice for terminal illness or unbearable suffering to avoid prolonged suffering”. It supports the sanctity of life.
The sanctity of human life does not require always saving or extending life whatever the circumstances and at all costs, Landman says. Nor is it inconsistent with shortening life in appropriate circumstances.
The question for medical ethics and legal interpretation of SA’s constitution, is whether AD is “a legitimate form of killing”. DignitySA says it is, with the constitution’s full backing.
SA’s constitution paved the way for recognition of socioeconomic and labour rights, the right to termination of pregnancy, the right to same-sex marriages, and the right not to be punished by death. “The living deserve the same right,” Landman says.
The Constitutional Court has shown linguistic precision in landmark rulings. For example, when decriminalising same-sex marriage in 2006, Justice Albie Sachs wrote that the law must “tolerate the pluralism of our society”. This principle could apply to end-of-life choices, says Landman, particularly given section 12(2) of the constitution.
SA “repeatedly congratulates itself “on being different and a leader in “unique ways”, he says.
“Why then should SA resist legalising AD if the constitution justifies it?” Landman asks. “Why invoke cultural, religious reasons to trump the constitution if it is not done in respect of abortion?”
He dismisses suicide contagion and slippery-slop arguments as untenable and not evidence-based.
“There is nothing sinister, inevitable or uncontrolled in the expansion of the scope of assisted-dying requests in different countries. It is a rational process of measured responses to patient need and equality or non-arbitrary imperatives, within the framework of laws of countries that allow AD.”
Holocaust references in the AD debate are “detestable and failure as an argument”, he says. Holocaust “euthanasia” is about murder born of hate, the non-voluntary killing of people against their will and death in the name of medical experimentation. “It is a euphemism for just plain murder.”
Coercion fears are not evidence-based. In most cases of AD requests, families act honourably.
Public opinion globally is clearly shifting. The UK’s AD bill is in committee stage, with final Commons votes expected by May 16 2025. UK polls in 2024 showed 73% — 75% in favour of legalisation.
SA-born former human rights lawyer Lord Joel Joffe would have applauded. Joffe represented Mandela and nine other defendants in the historic Rivonia Trial in 1963/4. After moving to London, he worked tirelessly in parliament, promoting humane laws on AD, which he saw as a human right.
In 2012 Joffe told me: “It’s a matter of time when, not if, the law on AD changes in the UK.”
In SA, expert analysis reflects complex realities contributing to the absence of AD:
- Cultural — many African societies view death as communal. Ubuntu challenges Western autonomy-focused arguments.
- Fears that AD could become a cost-saving tool in overburdened health systems.
- Religious — 63% of South Africans identify as Christian, often citing biblical prohibitions against “playing God”.
- Inequalities — comprehensive palliative care and social support are not available to all. AD could become an option of last resort for people suffering from poverty-related issues.
These obstacles are not insurmountable. Rwanda built one of Africa’s most robust palliative care systems post-genocide. In South America, Colombia and Ecuador, both predominantly Roman Catholic countries, have legalised AD.
Steps promoting SA as Africa’s AD pioneer include:
- Learn from allies: The ANC has close links with Cuba that quietly introduced AD in December 2023 under its public health law. It uses the terminology, “dignified death”, euthanasia and physician-assisted suicide for terminally ill patients. The Mandela-Castro Medical Scholarship bilateral programme sends students to Cuba for medical training and Cuban medical doctors to SA.
- Palliative parity: Invest in hospice care to ensure AD is not the only escape from suffering. Uganda’s unique model of training nurses how to manage pain in rural areas as part of palliative care shows promise.
- Legislative safeguards: Adopt Netherlands-style protocols, with two independent doctors confirming terminal illness, mental competence and enduring request.
- Traditional reconciliation: engage sangomas and spiritual leaders. The 2012 Traditional Health Practitioners Act provides a framework for integrating indigenous wisdom with end-of-life care.
- Continental leadership: Partner with the African Union to develop continent-wide guidelines, preventing “death tourism” while respecting sovereignty.
The legal prohibition of AD constitutes “abandoning patients in their final, dire need”, Van Niekerk says. “Patients lose dignity when beliefs of others override their legitimate preferences.”
Arguments for AD “outweigh those against it”, he says. When practised responsibly, AD confirms the four fundamental principles of medical ethics for doctors’ treatment of patients: refraining from doing harm (non-maleficence); promoting their best interests (beneficence); respecting their self-determination (autonomy); and treating them fairly (justice).
The Hippocratic Oath has been replaced by appropriate modern versions. Thus, the Declaration of Geneva contains no moral prohibition of AD and simply states: “I will respect the autonomy and dignity of my patient.”
“The time has come to recognise AD as a compassionate, peaceful, liberating, dignified, humane and caring end-of-life medical treatment option,” Van Niekerk says.
He exhorts fellow doctors: “Thou shalt not officiously strive to save lives when a hopeless outcome is inevitable.” He reminds them that it is “sometimes ethical to provide symptom control that shortens life”.
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