Assisted dying
- Wits University
Risks, trade-offs and possible ways forward — World Congress of Bioethics hosted by Wits underscores why it's a hard issue to resolve.
As South Africa confronts a Constitutional challenge over medically assisted dying, international experience offers no single ethical answer, only competing values and difficult choices.
At a recent bioethics discussion hosted by Wits University in Johannesburg, Henrik Ahlenius and Michael Lövtrup of the Swedish National Council on Medical Ethics presented a sobering picture of the international debate around assisted dying.
The two researchers were in South Africa for the World Congress of Bioethics, held on African soil for the first time and hosted by the Steve Biko Centre for Bioethics at Wits University.
Their presentation coincided with an important development in South Africa’s long-running assisted-dying debate.
In April 2026, DignitySA approached the North Gauteng High Court in Pretoria to request that the blanket common-law prohibition on medical assistance in dying be declared unconstitutional and invalid.
Three of the four respondents have now indicated their positions: The Minister of Health and the Health Professions Council of South Africa will oppose the application. The Minister of Justice and Constitutional Development will not oppose it and has said she will abide by the court’s decision. The National Prosecuting Authority has not yet responded, despite its deadline having passed.
DignitySA will now ask the Deputy Judge President of the North Gauteng High Court for a case-management directive setting firm timelines for the remaining papers and future exchanges between the parties. If this cannot be secured, a preliminary court date has been set for 18 September 2026, when DignitySA will ask the court to impose a timetable.
The Wits discussion underscores why the issue is so difficult to resolve
Ahlenius, whose background is in academic moral philosophy, and Lövtrup, formerly a medical journalist, did not make a simple argument for or against legalisation. Instead, they showed how every possible approach involves trade-offs between autonomy and protection, relief from suffering and the preservation of life, individual choice and society’s responsibility to provide care.
Professor Kevin Behrens, Director of the Steve Biko Centre for Bioethics, said the South African debate could not be separated from the country’s profound social and healthcare inequalities.
“There is no ethically risk-free position on assisted dying. The challenge is to respect autonomy and respond compassionately to suffering, while providing safeguards to prevent vulnerability, inequality and inadequate access to care from too strongly shaping a person’s decision,” he said.
Meanwhile, the Swedish National Council on Medical Ethics has considered assisted dying since the 1980s but has never reached a stable consensus. It has instead focused on improving the quality of public debate by clarifying terminology, examining international models and separating evidence-based claims from moral convictions.
What is assisted dying?
Terms such as euthanasia, assisted suicide, treatment withdrawal and end-of-life care are often used interchangeably, although they describe different actions.
The Swedish Council defines assisted dying as an intervention provided following an explicit request from a patient, where the intention is that the intervention should cause the patient’s death.
This excludes withdrawing or withholding treatment. It also excludes pain medication intended to relieve suffering, even where shortened life may be a foreseeable but unintended consequence.
Assisted dying may be self-administered, with the patient performing the final act, or practitioner-administered by a doctor, nurse or another authorised professional.
No single international model
Legal frameworks differ widely.
Some jurisdictions limit assisted dying to adults with terminal illnesses who are expected to die within six or 12 months. Others include people with serious, incurable and enduring conditions that are not immediately terminal.
Some recognise only physical illness, while others may consider psychiatric suffering under tightly controlled circumstances. Some require a person to retain decision-making capacity until the medication is administered. Others permit an earlier competent advance directive to remain valid after capacity has been lost.
A restrictive framework may provide stronger protection against error, coercion and abuse, but exclude people experiencing enduring and intolerable suffering.
A broader framework recognises more individual choice, but creates harder questions about prognosis, mental illness, vulnerability and whether suffering is genuinely irremediable.
“There are always trade-offs and nothing really removes the possibility of error,” Lövtrup said.
A system must therefore attempt to protect those who do not freely and competently choose assisted dying, without becoming so restrictive that people who should qualify cannot access it.
Principle and evidence
“The Swedish Council distinguishes arguments based on ethical principles from claims that can be tested against evidence,” Ahlenius said.
Principled objections include the belief that human life should not deliberately be ended, regardless of a person’s request, and that intentionally causing death is incompatible with medicine’s role.
Arguments in favour include autonomy, justice and the belief that competent people should be able to decide how much suffering, deterioration or loss of control they are prepared to endure.
Evidence cannot prove that autonomy is more important than the sanctity of life. But claims that vulnerable people will be disproportionately affected, palliative care will decline, or public trust in doctors will collapse can be investigated in places where assisted dying is already practised.
The evidence presented by Lövtrup complicates some common assumptions. In several well-studied jurisdictions, people accessing assisted dying have been more likely to be highly educated, comparatively affluent, urban and accustomed to independence, rather than society’s poorest people.
However, this evidence cannot simply be transferred to South Africa, where access to healthcare, pain relief, disability support, and home-based care is deeply unequal.
A choice may be formally voluntary but still arise within circumstances where treatment and support that could make life bearable are unavailable.
Care, dependency and choice
Good palliative care can reduce some requests for assisted dying, but international experience suggests that it cannot eliminate them.
Physical pain is not always the main reason people wish to hasten death. Some fear losing control, becoming dependent, being unable to communicate or no longer recognising themselves in the life they are living.
“For some patients, simply knowing assisted dying is available provides reassurance, even if they never use it,” said Ahlenius.
But this presents a particularly difficult question in South Africa: should assisted dying be considered before the country can provide adequate palliative care to everyone? Offering assisted dying where care is absent risks making it a substitute for pain relief, psychological support and human companionship.
Yet withholding it until healthcare inequality has been solved may require individual patients to endure the consequences of a failing system.
Can safeguards remove risk?
Every assisted-dying framework requires voluntariness and decision-making capacity. In practice, these are difficult to assess.
A person’s decision may be influenced by depression, fear, loneliness, financial pressure, inadequate care, family relationships or distrust of medical institutions. Coercion is not always explicit. It may take the form of a person believing that others would be better off without them.
A highly restrictive system may wrongly exclude competent people whose requests are informed and enduring.
“The question is not whether risk can be eliminated, but which risks a society is willing to carry,” says Behrens.
A debate South Africa cannot avoid
As the case moves towards the North Gauteng High Court, institutions like the Steve Biko Centre for Bioethics have an important role to play. “We’re not offering easy answers, but we hope to ensure that the public debate is informed by evidence, international experience and a clear understanding of the values at stake,” says Behrens.