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Jessamy: Thanks for joining us for this episode of The Lancet Voice. I'm here with my co host Gavin Cleaver. Today we're talking about death. If you've recently suffered a bereavement, you'll notice that our tone, for the most part, is cheerful. This is not to diminish the loss that death brings, but because the work discussed here is trying to explore a new relationship with death.

But if you're in the acute phase of grief, this episode might not be right for now. As always, if you'd like to reach out to Gavin or I to discuss, please get in touch with us on our Twitter handles at jessamybergenal or at Gavin Cleaver. 

Gavin: Thanks, Jessamy. So today we're going to be talking about a new commission from The Lancet called The Value of Death.

It asks and attempts to answer some of the big questions about death, like what is a good death? How has our relationship with death changed over the last few years? What can we practically change in a health system about how people die for the better? To find out how we can better come to value death, Jess and me spoke with some of the commissioners.

So you'll hear her speaking to Dr. Richard Smith, who's former editor of the BMJ, Dr. Libby Salnow, a palliative medicine consultant, and Dr. M. R. Rajagopal, chairman of Pallium India and director of the WHO Collaborating Centre for Policy and Training on Access to Pain Relief.

Jessamy: We're so excited to have you here. Everybody at the Lancet is extremely excited about this commission and it's great to have this sort of, four or five way conversation. Richard, maybe I could start with you. What, how did this commission start? It's an unusual topic for a medical journal.

Richard: It started really with the conviction that there's something very wrong with our relationship with death. The relationship might be described as unhealthy. Death is part of life, it's a very important part of life. And what was interesting, when I talked to people, all sorts of people, doctors, nurses, patients, people who've had family experiences, almost everybody agreed.

Something is wrong. There weren't people who said to me there's no problem here at all, what on earth are you talking about? And I think we started a lot with the idea that there was this sort of excessive treatment at the end of life, a tendency to go on and on beyond the point that really made sense, increasing rather than decreasing suffering.

And then when we began to think about it more broadly, we realized that also somehow death had just become far too much. The business of doctors and nurses and health professionals, that it had moved away from the community, which is where it used to be probably until about the 1950s. And we were very interested to analyze the difference between how people died and how people thought about death in the 1950s and how they think about it now.

And there's been a very dramatic change, not least in the way that people die. In those days, Deaths were often faster came earlier. Now often death is a very prolonged process. So the nature of death has changed. In a way, society and the health system haven't responded. Which actually in some ways is what in the health system generally.

It was set up to deal with acute conditions and trauma. And it doesn't cope very well with what the predominant problems are now of long term chronic conditions. 

Jessamy: In my head, I've got this sort of tension between high income countries and lower middle income countries when we're talking about this.

Maybe we'll park that for later, because I think we can talk about that, that later in terms of that, the unnecessary deaths that also go on in the world, even though in some places we're hanging on to life. But I think this work started before COVID 19. What kind of a lens? Has the last two years put on this work?

Richard: Yes, when the pandemic broke and, the people were very concerned about what was going to happen, there was an expectation of huge numbers of deaths. Our initial reaction was. Oh my goodness, who on earth is going to want to hear anything about the value of death in these awful circumstances?

And we had a meeting of the commissioners online, and we started almost with the idea that we might have to abandon all of this. But very quickly, within that conversation, we went on for an hour or two, we came to the opposite conclusion. That actually, if we had moved to the kind of world our report is advocating, then we'd be in a much, much stronger position.

Instead of people dying at home in awful circumstances with very little support, there would have been. much more community support. 

Jessamy: Yeah. Fascinating. And Libby, you're a practicing clinician. Maybe you could just add on to that your perspective about the last couple of years and what this commission means.

Libby: Yeah. So I was working as a palliative care clinician during the COVID pandemic when particularly when the first wave started. And I think for me, it really exemplified why. this commission is so urgently needed for us to understand what our kind of relationship is, what our understanding of death and dying is today.

And I saw two very polarizing experiences of people's deaths and of people's bereavement at that time. I was seeing people at home and often health services had completely withdrawn. There were no home visits. And people were caring for their loved ones with some video calls from healthcare professionals, but no other support, often very limited symptom control, so for breathlessness or any other symptoms.

But what they did have was connection, strength, that ability to be together, to reflect on their lives, make sense, and connect with the people who were really important to them. And what I saw for people who were in intensive care or even just on the usual, the normal wards in hospital was that they had all of the kind of medical care and, The ventilation, oxygen and to some extent symptom control for breathlessness and other difficult symptoms.

But their families were only connecting digitally by through FaceTime on iPads held up. And so the, these deaths would entirely devoid of all of that connection, that meaning that ability to have those last conversations or reflect on your life or be present and for that death to be part of that family's.

story. It was alien. It was something that they had never, could never really experience fully. And that really demonstrates the kind of polarizing experiences. And it's an extreme example, but we see these polarizing experiences throughout all countries in the world. Either, we don't get the balance is what it seems to me.

And that's one of the driving forces for me and why I think this commission is important because We need family and community connection. You need meaning and relationships at the end of life. You also need pain relief when you need it, and good symptom control and good medical care as and when you need it.

But the balance has got completely wrong. And we see this throughout different contexts. And Raj, I'm sure will tell us about, different settings, that this isn't something unique to the UK or to high income countries. This is something that we're seeing globally. 

Jessamy: And maybe that could just lead us into the next sort of topic that.

I wanted to talk about is this tension between low and middle income countries and high income countries and under five mortality, which is obviously drastically bigger in low and middle income countries. And that the name of the commission value of death, there is a suggestion that we've diminished the value of death in many high income countries.

And that's actually, we've lost the focus on the value of life and the value of health. And Raj, I wondered whether you could just talk a little bit about your perspective on that tension and what it means to place a greater value on death. In terms of how we perceive and frame health. 

Raj: Advent of modern medicine and our current civilization has actually diminished the value of death and is more and more making death the enemy.

It's actually happening. We have this paradox that 96 percent of people in my country and in most of the low and middle income world, which is 84 percent of the global population, has very little access to pain relief. Symptom control. If you are breathless, you just get curative treatment and nothing else.

On the other hand, despite that, when somebody's dying, then modern medicine steps in and provides life support. Forbidden death. You cannot die. If you have money in the pocket, you would still be put on a ventilator. And if you have more money, you will be put on an ECMO machine. Now, this It's not only a matter of money, certainly it's a huge issue of catastrophic health expenditure.

Where in my country, 4 percent of the population is subject to catastrophic health expenditure every year. It's a growing destruction. That's on the one spot, but it's not only the money. We are taking away everything valuable surrounding the time of death. The time where you can receive a lot of love and give a lot of love, mend broken relationships, say I love you, be treated with a kiss on the cheek, all those things are being cruelly taken away, where people are shut down in intensive care units, and even in COVID 19.

Yes, death is more familiar. Death is more familiar as an enemy to be beaten at all costs, not as something that you live with. And after COVID 19, the devastation of families deprived of a final look or a final touch. You mentioned video calls. I know so many institutions where as soon as they enter the covid ward, the mobile phone is taken away, put in a wrap and stored no contact.

It's cruel. It's happening here. 

Jessamy: And what does that mean for you in terms of the philosophy of death? In terms of what we place the importance on, in, in the way that people die and what this commission adds to that. Do you set out a framework for how we should all die, or is this more explorative?

Raj: The most important thing, one of the recommendations of the commission is to familiarize death again to the society. It should it's a matter for public discussions. In just a quarter of a century, death has been forbidden. in intensive care units. The only way of changing that is for the public to be encouraged, to think about it, talk about it.

People who have gone through the difficult journey, people who have suffered the horror of a family member, they have no voice now. They are there, willing to speak. One of the things that needs to be done is to give them a voice, hear their voice, And over the next few years, to make sure that the person on the street understands what is being done to themselves and to their families.

Jessamy: Why? Why have we diminished death? What's the historical, social, sociopolitical analysis behind what's happened here? I know it's going to be, it's huge, but what are the, what are like the, what are the three main reasons why we've done this? 

Richard: Yes, I think you're asking me a very difficult question here.

One of the crucial things in the report is a chart that makes a lot of comparisons between the 1950s So I've already mentioned how death has become much slower. It's happening when people are much older. The technology has advanced enormously. When we have drugs for cancer, as we have that might cost 20, 000 pounds a year to administer and can keep some people alive for another few months, the technology has changed.

But also the social context. Probably back before the 1950s, death was much more to do with the church and religion than it was to do with health professionals. But clearly there has been a big decline in religious beliefs. You asked me for three factors, those are three I would pick out.

But it's much more complicated than that. A central idea in this report, is that, death, like everything else actually, exists within a complex system. There are many different factors at work. So you might start by saying if people are being over treated at the end of life, that's clearly the fault of doctors and health professionals.

But it's not. There are all sorts of factors that are pushing both patients and doctors. to go in that direction. So I think unfortunately that's it makes for quite a complex report, but I think it reflects a greater reality than saying, here are three problems and here are four solutions.

Jessamy: No, I think that's right. It's the political economy of death, right? The market forces of driving death. Anyway, Libby you wanted to say something. 

Libby: I wanted to pick up on one of the points that Raj made around the unfamiliarity of death and kind of the role that plays in where we find ourselves today.

And I find seeing people at home as I go to care for them, if they've been referred into our palliative care service, people often talk about how unfamiliar they are, how frightening this is, how they've never seen someone die. They've never cared for someone in the last days of life. And. The table that we have in the report that Richard has alluded to, it describes how, life expectancy is increasing.

People then have stopped dying at home. People are often dying in hospitals or in care homes or in other institutions. So it's hidden away. Those final hours often are people are not present for, or if they are, they're just sitting passively. They're not actively caring. That's a job that's often done by nurses, doctors, healthcare assistants, other professionals.

So there's this sense that it's becoming. increasingly unfamiliar and people don't have the skills and the skills are seen as this professional remit. You're knowing what happens if someone's skin becomes cold or their breathing changes. These are skills that actually in other times and certainly in other countries currently, these are core human community skills that people know about and and get passed on, but in certain particularly high income.

countries. These are being lost, so they're not being passed on. And that feeds this fear of death being something other, unfamiliar, that communities don't have the skills and confidence and shouldn't be managing. And so then that feeds into this kind of further professionalization. And what is one of the kind of the real challenges, because then If one of the main parts of the report is to say we must challenge this kind of over professionalization.

We need good medical care, you need good symptom control, but it can't be the entirety of our response to death and dying. So when you ask and try to push professionals and institutions back, communities also need to feel confident to take this on. So there needs to be a way of supporting everyone to understand how to respond.

Respond to death and dying. What signs mean? How do you care for someone who's caring for someone else? How do you support them? How do you turn someone so that their skin is supported? How do you keep their lips moist? How do you support someone who's been bereaved? And these are common skills that we need.

as human beings, because these are common universal events that will happen to us all, but somehow we've lost that sense that these are universal concerns for all of us, and we've lost the skills to respond to them. 

Jessamy: That's fascinating. We're very shortly going to be interrupted by my 

Libby: son.

It's just coming back from school. My children always come up to my laptop and read what's on it and they say to me, they're little, six and eight, Why are you always writing about death? It's not that interesting. Yeah, 

Richard: so my children, who are much older, say that's 20 seconds we've been meeting and you haven't mentioned death.

That's a record. 

Jessamy: But there's also an obsession that they go through with death. Because it's such a, a huge thing. And we've gone through that recently with our, five year old who asks a lot about death and what it is and where it goes. And I fear that We try and make things up.

You suddenly have these fears over you completely ruined their relationship with death for the rest of their life. You've spun them this tale. 

Libby: I think it's an important point, thinking about kind of loss and death and pain and sadness. And these are normal human responses to things that will happen to us.

And it's also very normal to want to protect each other and, to protect children, to protect your loved ones, your husband, your wife, from these things. And those things are okay. They're normal responses. It's how we can't help but to behave. But the problem is that the entire society becomes colluding in that we try to pretend that actually it doesn't happen and if we push death away and we don't see it and we don't have to deal with it then actually we somehow save ourselves from the pain but what happens is it comes back in another way and actually that we talk about the gift of death and again this is quite a kind of obtuse concept I think to try and understand but the gift of knowing someone's going to die is Being able to be with them, supporting them in a way that you know they would want to, allowing them to die, hopefully free of symptoms, that are managed in peace, having done the things they wish to do, and having said the things they want to do, with the people they wish around them, is an enormous gift.

And we talk about, this has been written throughout history, of the gift of being able to give that, and also to receive that sense of completion, that you have done, you've supported someone you love well. And, there is something in that, in a kind of reciprocal gift relationship in that. And we try to unpick that in one of our panels.

Richard: Yeah, one of the things we examine in the report is the very serious amount of investment and science that is going into trying to achieve something close to immortality. It comes in various ways and we describe those, but it's a massive enterprise. Yes, it seems to us very bizarre. It very much fits with the whole sort of West Coast, Silicon Valley kind of view of the world that, given enough time and resource, we can fix anything.

And that, that, that idea that we are out to try and defeat death, to get rid of it all together. And I think it raises questions about, what exactly is medical research trying to do? There are massive investments. In trying to cure cancer, there are very tiny investments in palliative care research or helping people to die.

And one of the things that this sort of made us think about is we seem to be as, trying to defeat death. And that relates rather closely, where does that idea that somehow we're masters of nature, not part of nature. That's exactly what has fed the COVID pandemic, that we somehow, we've ignored our relationship with nature we've pushed, wild animals out into the edge where we then there's an interaction with human beings.

And then it also makes us think about climate change again. And there's a lot about climate change in this report, because I think you're the same idea that says we can defeat death. suggest that we can master the planet, that we can master nature. And I think that the way that these things come together is very central to the report.

Jessamy: And maybe, the reflections on climate change are really interesting. Maybe you could just expand on them just a little bit in terms of what that means about our perception of risk, our perception of where we are at the moment with climate change and how we feel okay to, to dominate it in, in, Carry on as we're going.

Richard: Yes, perhaps the most useful thing to say is it made, I am the chair of the UK Health Alliance on climate change, which brings together most of the medical royal colleges and the nurses and the pharmacists, the dentists, and does in fact include the Lancet. And it's made us reflect, or it's made me reflect a lot on the nature of our health system.

Just like our whole economy. is out of control, that we're consuming far too much, we're exploiting nature far too much. Actually, exactly the same thing is going on within healthcare. The NHS is 5%. of the UK's health admissions. In the US, it's 12%. It's a massive production, not only of greenhouse gases, but also of waste.

A lot of the plastic that is in the oceans has come from healthcare. We in healthcare need to think about our own Production and that perhaps healthcare, and particularly I would say in the way we overtreat people at the end of life and spend enormous amount of resources on ke keeping people alive just a little bit longer, that our health system in some ways is out of control as our economy.

Raj: To add on to what Richard said, yes, it's a matter of enormous cost and destruction of families, but it's much more than that. It's also prolongation of suffering. The person who could have been cared for and would have died in reasonable comfort in two days has the death being stretched out over a period of two months at not only a huge cost in terms of money, but also at an enormous expense in terms of the suffering of that person and of the whole family.

Libby: And we talk a bit about the kind of paradox of over treatment and under treatment that we see throughout all countries, where the high, low or middle income, there's huge variations within countries. And there's both kind of the over treatment, and there's a huge literature on, futile treatments, and the cost of treatments that are known to have no benefit.

And yet, we're continuing to And then, there's potentially inappropriate treatments that are really unlikely to prove, to give benefit but may, and people may wish to try them. And there's the kind of that overtreatment that, is uncontested. We know that is existing.

And I think thinking not only of the financial cost and then of the kind of social justice and equity issue that this money, This is limited funds that cannot be used to be spent elsewhere in either the health or other areas of society, but also on the carbon cost of that now. And I think that's something that we need to start understanding that if it's really, as treatments are really futile, then actually the carbon cost is something that needs to be taken in.

And then that's. Seen in parallel with the kind of shocking undertreatment of pain, of symptoms at the end of life, and this attention to ideas of suffering that modern healthcare just cannot address. And the earlier palliative care commission that Raj was part of really illustrates that, to demonstrate that it's one of the, most shocking inequities of health.

At the moment, these, managing pain at the end of life with low cost, easily available opioids is something that should be universally available and it's available to just a tiny proportion of the world. That's one of the most urgent challenges in terms of global health at the moment.

Jessamy: I just wanted to ask about COVID 19 because, there's some interesting conversations going on in the UK at the moment. about what it means for levels of flu per year. Should we be allowing X number of people to die of flu each year when we know that there are things that we can do to stop it?

Richard: The reality is that there are many different causes of death. I think back to when I was first at the, I used to be the editor of the BMJ, and when I started there in 1979, there were, I can't remember the exact numbers, but there was something like 10, 000 deaths a year on the roads in Britain plus enormous damage, for every death, there are many people who are seriously injured.

And somehow, people, it wasn't debated very explicitly, but somehow that was accepted. And actually it has been steadily reduced since. So I think there are many areas where there is some sort of implicit, often not well articulated, calculation going on about how valuable lives are. And, obviously I suppose now people draw parallels.

We know that there are deaths from flu every year. And it's to be expected that there will be deaths from COVID too. And it can't make sense to try and eradicate every last death, but I think if we were to talk about death and dying much more, perhaps we would be able to have these discussions.

In a more positive, open way. I think, the report, we have a lot of analysis of costs at the end of life. And it comes out that something like 10 to 15 percent of the expenditure of health systems, this is not just the NHS, but across the world, is on people who die in that year. Now, if all of those people were having all sorts of suffering reduced, and there was lots of benefit, Then, perhaps that could be tolerated, although that, viewed from a society's point of view to be spending, 10 to 15 percent of the biggest, usually the biggest public expenditure is healthcare on people in the last year of life.

Does that make sense? In a broader view, could we possibly have a discussion about that? It seems to be a very, there's this awful tendency to think we've just got to treat this person. We've got to do everything we can to keep this person alive. And yet, often, as Raj has expressed so beautifully, actually we're increasing suffering.

We're not decreasing suffering. The sum of suffering is increased. Viewed from an economist's point of view, that potentially looks like a very bad investment. 

Libby: The whole narrative is quite skewed because this idea of kind of the cure and, medicine has made huge increases in life expectancy and cure rates for many conditions and, things that were previously, lethal are now being cured.

But I think the whole debate for me is just unbalanced and missing a key. Component that I hope this commission can bring to the debate is that if you avoid a death from any cause X, Y, Z, that's not preventing death in itself. It will still happen at some point to that person from another condition.

But the way the language is turned, it is framed the sense that's been saved and death has been defeated. It's been averted and somehow we never quite acknowledge that at some point it will come. You think it's infinitely deferrable. And so the language is very dangerous in that way because it's beguiling.

It makes you feel that we've defeated another death. That person will live forever. They can't and they won't, we don't want people dying from avoidable conditions. We want to avoid early deaths on, and that's. been one of the kind of achievements of public health. If you look at under five mortality, maternal mortality, death from communicable diseases, these are things that should be defeated.

And we have the capability we should do. But what we're not doing is defeating death per se. We're reducing deaths from avoidable causes. And so any push to increase our input into delaying death for these. These causes, say, for example, flu should always be accompanied with an acknowledgement that death at some point will happen.

And so increased funding and support should be going in parallel to supporting people as we know they will die, ensuring that suffering is managed, ensuring that sensible discussions are had ahead of time so that people can make decisions about the extent, the quality, the quantity of treatment they have, the wishes that their loved ones would have around that time.

And that you can balance the kind of medical. physiological biomedical input with meaning, sense, connection, existential issues that at the moment just have no place at that table. 

Richard: One thing we look at in the report is the concept of a good death. There's a lot of talk of a good death and lots of attempts to define a good death.

But I think our general conclusion is that's not, it's turning death and dying potentially into a sort of bureaucratic. tick box exercise. 

Libby: And I push even within palliative care, there's a kind of this tension between kind of the relational aspects of what's happening with, people as people and understanding that context and also the kind of kits that you need to get to die at home.

And that is a hospital bed, injectables, a district nurse referral, incontinence pads, a commode, all these things. And they do, for some people, they do really empower them to stay at home and they lead to great symptom relief, but they've become the whole purpose. And actually, all they're meant to be doing is enabling you to stay at home to then have these conversations, be part of whatever kind of community or conversations, whatever's important to for you at that time to make sense of it, but they've become the whole.

center stage. So the tick box list is there and it's now pushing out those other really important conversations and those kind of deathbed scenes where you're, having conversations with people about what's important and that last opportunity. And that's, I think, been forgotten. 

Jessamy: Yeah, I think that's right.

And it's such an, it's such a great topic and it feels like just the beginning in some ways, this is the beginning of hopefully some more, something more meaningful, something bigger. What, what could, what did you have to miss out in the report that you want to carry on forward? What does the afterlife of the value of death commission look like in an ideal world?

Richard: Certainly, right at the beginning of this commission, when we asked people what they wanted out of this, people said we really want, Is not just, a written report. We won't change and we do have a lot of recommendations and we plan to have further meetings moving all this. forward. And I think that's going to involve a lot of research and a lot of thought.

But I wanted to make the point that in the report we have the principles of what we call a realistic utopia. Again, an idea that Richard Horton shared with us that comes from the philosopher John Rawls. Not a utopia that's completely unachievable, but what would that look like? And we've described much of it during the And I think something that's very important in the report is that actually, Raj will deny this, but something not that far away from what we describe in the realistic utopia already exists.

It's in Kerala. So this is not something that, is pie in the sky, completely unachievable, but it will require a lot of change. And to go back to this point about systems, it will require systems change. It's not, you can do three things and that'll be the end of it. It's going to be more complicated than that.

Jessamy: And just for our listeners, because everybody's now going to be wondering what is going on in Kerala, Raj? 

Raj: Kerala, the successful experiment. has been in giving health care back to the community. Engaging the community. It started with the health care systems opening their doors to the community.

Engaging with volunteers from the community as partners. And they be allowed to participate in care process. And small communities emerge. They form their own initiatives to look after the ailing people. in their neighborhoods. I would say it's more about life than death. People living with illnesses are cared for by the people in the locality and then facing death becomes a natural sequence.

What has become unfamiliar in 25 years is now being familiarized again. And Libby has done this in 30 counties in the UK, where again, the community is getting engaged. We have known this for a long time. In 1978, the Alma Atta Declaration asked all countries to engage, to partner with the community. And in 2018, they reiterated their commitment.

And went one step further in the ASTANA declaration and asked control over healthcare be given to the community. And everybody knows that this is to be done, but what has been achieved already has to be built on and spread on a much wider scale. It may not suit the healthcare industry very much. That's a challenge that we'll have to face.

It is a challenge. It is possibly the greatest challenge, whether it's about life or death. The greatest challenge could be that one. It's a huge issue. Not easy to address, but the only way of addressing that challenge is also with the community. 

Jessamy: Thanks, Raj. Libby, some final reflections? 

Libby: Yeah, so we describe the idea of the realistic utopia and this set of principles that we hope will be a kind of catalyst for action, radical but achievable, the power does sit with all of us to make these changes and we give recommendations.

through from civil society, governments, medical research funders, researchers, practitioners, right the way through. But we know that there are lots of examples of where this is happening already, and we give a great deal of time exploring and understanding the model in Kerala, which gives the most comprehensive example of how you can do this across multiple systems.

But we know there are examples, and we give a few in the report, but what we're hoping this report will Stimulate is experiments for people in embedding, actioning, making the realistic utopia happen in their context. And we're going to build a collaboration to hear from people so people can experiment, understand, feedback, and we're wanting a growing community really of.

Practice of innovators, of radical change makers to take on parts of this report, whatever resonates most with them and works most in their local context. And so we are looking for people to get in touch. We're gonna be setting up a website and there'll be a way that people can share these stories, experiences, experiments.

Gavin: Huge thanks to Richard De Libby and Raj for speaking with us and sharing their thoughts there. For a bit of intra Lancet chat, Jessamyn and I are also joined by Dr. Jocelyn Clarke, who's Senior Executive Editor at The Lancet, and the person that's been managing this commission internally. Hello, Jocelyn.

What I guess I'm keen to know is how this commission came about. What was the philosophy behind the commission, if you'll excuse the pun. 

Jocelyn: The Lancet, of course, is known for Always being interested in the social and political contexts of issues of importance to health and clinical medicine.

But here it was really important to surface a variety of different disciplines. Philosophy, history, sociology. Alongside some of the clinical disciplines like palliative care and others. So that we could begin to interrogate. That unbalanced relationship between medicine and death and dying. 

Gavin: How do you think that this fits in generally with with The Lancet?

When people think about The Lancet, they think about medical publishing, the latest up to date scientific research. We obviously publish a lot of perspectives and philosophy, but this commission that's quite philosophical is quite a new venture really, isn't it? 

Jocelyn: Yeah, it is in some ways, because it probably seems to Some readers that it's actually a bit contradictory or a bit of a conflict that is, recognizing that death and dying in our societies are overly medicalized, but as a medical journal, having contributed in part to that medicalization that we should be the ones to, convene a large group to unpick that relationship and, Come up with new ways of rebalancing and visioning that relationship.

But we have, a long history of being interested in the social and political, and as you say, the. Medical humanities as a context for understanding contemporary issues in health and clinical practice. So it does in some ways feel really natural to us, and it's certainly because it takes such a critical approach and brings on board these multidisciplinary perspectives to look at the relationship.

between medicine and death and dying. It's a great amount of value that we can bring as a medical journal to show our audience and readers that, the ways that death and dying are delivered now haven't been how they've been conceived of in the past. And it's 

Jessamy: an extremely fulfilling and emotive read really without being at all sad or any form of a downer.

It's a really uplifting read. What are some of the other pieces of work that are going alongside this or that are going to happen in the future? 

Jocelyn: I quite agree with you that the commission, I feel exactly the same way. It is very emotive, but I feel like it has such A sense, a feeling of energy that it almost creates, a kind of outrage as a reader that there are that the contention that the commission started with death and dying have, turned into these phenomenon that are very much removed from family and community.

overly medicalized and that indeed there is a lot of fear and anxiety associated with it. So it's a very sort of motivating read and it's incredibly readable, as you say, in the sense of really blending a lot of empirical data with analysis from these different disciplines and setting out some very, to some people, this will seem very radical this idea of a real realistic utopia that the commission commissioners put forward in addition to the commissioners report in the Lancet, we have 2 other pieces.

1 is a commentary that's been written by Liz Grant, who's a global health scholar and clinician in Edinburgh and her co author. Farzana Khan from Dhaka, Bangladesh, and they talk about the precariousness of balancing life and death and really very much bring to this conversation, the importance of looking cross culturally and recognizing the various, contradictions, the nuances the complexities.

Of trying to rebalance this relationship that medicine and society have with death and dying, particularly from the perspective of lower and middle income countries. And then we also have a really wonderful profile of Roz Taylor, who is one of the commissioners of the commission report and is the strategic medical lead at Harlington Hospice.

In London and she's the former head of hospice UK. So together I think those are really nice pieces that frame and compliment the commissioner's report.

Gavin: So this has been The Lancet Voice. You can read The Value of Death Commission online now completely for free at thelancet. com. You can of course, if you're not already, also Lancet Voice wherever you usually get your podcasts. Thanks so much for listening and we'll see you again in two weeks time for another 

episode.