Intended for healthcare professionals

Education And Debate

Historical and cultural variants on the good death

BMJ 2003; 327 doi: (Published 24 July 2003) Cite this as: BMJ 2003;327:218
  1. Tony Walter, reader in sociology ({at}
  1. 1 Department of Sociology, University of Reading, Reading RG6 6AA

    Dominated by religion in the past and by medicine in the present: the idea of what constitutes a good death has changed in different cultures and societies throughout history, perhaps nowhere more so than in our globalised, Western cultures. After a period of individualisation, shared experiences with fellow sufferers now seem to be increasing in popularity

    Here is an account of the death of a French peasant in the 19th century:

    “She contracted a summer cholera. After four days she asked to see the village priest, who came and wanted to give her the last rites. 'Not yet, M. le curé; I'll let you know when the time comes.' Two days later: 'Go and tell M. le curé to bring me Extreme Unction.' “1

    This woman died a good death according to the lights of her society, but this is very different from the good death of modern Western societies. Firstly, she wanted to see the priest, not the doctor; today, dying is ruled not by religion but by medicine. Secondly, she died in a local community in which everyone knew their script; today, palliative care encourages individuals to write their own scripts for dying, as they do for living. Thirdly, the ars moriendi of her time assumed that she would die in a few days of an infectious disease; today, we are struggling to learn how to die much more slowly of the degenerative diseases of old age.

    The good death depends on one's society and culture. Norms for the good death therefore vary widely within a multicultural society. In this article, I argue that cultural norms about the good death depend in particular on, firstly, the extent of secularisation, secondly, the extent of individualism, and thirdly, how long the typical death takes.

    Religion and secularisation

    In tribal societies, to belong to the tribe is to adhere to the tribal religion. In many societies one particular world religion is the religion of that society, and it is expected that members of the society adhere to the religion. Religion is in part what glues such societies together.2 The death of any one member undermines the family, the community, and even (for individuals of a high social status) the entire society, so it is important that death is managed according to the required religious rites, for it is these rites that glue the group together at precisely the time that it is most threatened. One sees dying according to the book today in those societies that are dominated by Hinduism,3 Islam, Judaism, and Catholicism.

    But many modern Western societies are not like that. Firstly, many have been influenced by Protestantism, which is founded on the belief that there is nothing the living can do to help the soul's passage after death. Secondly, most European societies are now highly secular, with only around 40% of Europeans believing in an afterlife, although this goes up to 75% for the Irish (north and south) and for Americans.4 For many people today there is thus no afterlife to prepare for, on one's deathbed or at any other time. More importantly, whatever individuals believe, modern social institutions (and this is as true of the United States as of Europe) presume that this is the only life.

    Embedded Image

    In a meeting, King Sobhuza II of Swaziland (1899-1982) dismissed all of his advisers, except the minister of health. To him, the King said, “I am going.” Confused, the minister asked where. The King smiled, waved goodbye, and died

    Credit: TOPFOTO

    So, thirdly, religion becomes a personal choice, even in a religious society such as the United States. At first, this meant the choice to choose a particular denomination, but increasingly it means developing one's own personal spirituality, in which bits and pieces of any religion or none may be mixed and matched. The ultimate authority is not one's community, nor the sacred text of one's chosen religion, but “what works for me.” In Britain, this is now reflected in healthcare chaplaincy, which increasingly sees its task as helping patients to discover their own spirituality and find their own path through illness or death.5 It is also true of the hospice movement in English speaking countries—in many other countries hospices have more traditional religious practices around the deathbed.

    Community and individual

    For reasons that are still, despite the best efforts of historians,6 lost in the mists of time, the English have been among the most individualistic of peoples. This goes back to at least the 12th century and has profoundly influenced how English culture7—and its colonial child, American culture8—approach both life and death. It is probably no coincidence that Britain took to the Reformation, with its individualistic relationship between individuals and their saviour. It is certainly no coincidence that modern palliative care began in England, rooted easily in the United States and other former colonies, and struggles in countries such as Italy, where the family takes precedence over the individual,9 and hierarchical Japan, where doctors' orders have much greater weight than patients' preferences.10

    Although palliative care is publicly against active, voluntary euthanasia, the two actually have one thing in common. Both find support in individualistic societies that promote personal autonomy—the right of individuals to make their own choices about how they should live and die. For advocates of both palliative care and euthanasia, the good death is one in which I make my own choices about my last days and months. In individualistic societies, the bad death is that of the person with no autonomy: the patient with stroke or Alzheimer's disease, who cannot communicate his or her wishes or whose brain has so deteriorated that there are no wishes left.

    Individualistic societies (and these are often secularised Protestant societies) have very particular notions of the good death. But these societies are now typically multicultural, and the majority notion of a good death may not be shared by minority groups that pay more respect to religion, family, or community. One Hindu describes their practice: “The belief is that you should die on the floor. Here a lot of people die in hospitals and a lot of us families are very shy to ask for what we want. We feel out of place, like a Muslim praying on the factory floor.”3 Dying on the floor, with a dozen or more family members praying and chanting, is certainly not the normal way of a British hospital and may disturb other patients as much as staff. Second generation migrants from the Indian subcontinent may have different views again, as a Sikh doctor notes with some nostalgia:

    Summary points

    A good death depends on culture and changes over time

    There are different notions of the good death, especially in a multicultural society

    Religion and secularism influence ideas about the gooddeath

    Individualistic societies promote the personalautonomy of the dying, including palliative care andvoluntary euthanasia

    A challenge today is how to die well from the slowdegenerative diseases of old age

    “In India the older generation would keep old folks at home because they would have had the experience of supporting the dying at home, but here people expect health care professionals to do it.”3

    Quick dying, slow dying

    The ars moriendi of the Middle Ages, in which dying people made their peace with their Maker, presumed that the person concerned would die in a matter of days. Now, however, modern medicine can diagnose early, but rarely cure definitely, major killers such as cancer, heart disease, dementia, and HIV infection. A lot of us are walking around knowing that we, or one we love, have a life threatening illness; and we may have to live with this knowledge for decades. Even when the terminal period starts, the doctor may tell us it will be months, or even a year or two. So the question about how to die well today is how to live for months, or even years, knowing that we are dying. This question is what both the palliative care and the euthanasia movements are addressing. It is also the question that many people who are caring for family members with stroke or dementia do not know how to begin to address.

    Embedded Image

    Suttee: An Indian widow burns on her husband's funeral pyre

    Credit: MEPL

    Many of us would like to go out like a light one night after 20 years of active retirement, a good round of golf, and a nice meal, but we know the chances are slim. Few will have this privilege of sudden, unconscious death; many dread the lengthy, conscious death of cancer or dementia. So in Britain a ready market has developed for autobiographical books, newspaper columns, and television programmes about dying slowly, informing a perplexed society what it is like to die of cancer11 or care for someone with Alzheimer's.12 We are witnessing the development of a new art of dying,13 with hospices, journalists, and dying people themselves writing the scripts for a new heroism in the face of the old Grim Reaper.14

    I began with a quote from a rural society, in which people died at home, surrounded by family and neighbours, helped on their way by the priests' rites. By the end of the 20th century most people died in hospital, surrounded by tubes, relays of nurses, and junior house doctors. Nowadays, dying can take years in which medical staff may be present for only a few minutes, and family members have moved to the other end of the country or are left behind in Iraq or Zimbabwe. In this ultra-individualised, ultra-globalised world patients are increasingly finding their own paths, in the company of other patients, whom they meet through the internet and self help groups. So the last, perhaps prophetic, word goes to the founder of BACUP (the British Association of Cancer United Patients), which attempts to combine medical knowledge with that of patients and their families: “I finally met a fellow young patient with ovarian cancer. We shared our experiences… Through this, I realised that other patients could give me something unique which I could not obtain from my doctors or nurses, however caring.”15


    • Competing interests None declared.


    View Abstract