Article was originally published in The Lancet on 08 March 2025. 

Libby Sallnow is Associate Professor in Palliative Care in the Marie Curie Palliative Care Research Department at University College London, UK, and a consultant at the Central and North West London NHS Foundation Trust. She is also a lead author of the 2022 Lancet Value of Death Commission. “I really don’t believe in one answer, and I practise that in medicine”, she tells me. “I’ve always lived in the grey, I think.”

This perspective was encouraged early in her life. Sallnow does not come from a medical background; her father was a social anthropologist, her mother a religious studies teacher. She spent her early years in Peru as her father studied the blending of Catholicism with local religious practices. His fascination with how different perspectives meld and transform, and can imbue the same object or concept with multiple meanings is something Sallnow has inherited. And her father's story is also key to understanding why Sallnow has made it her mission to change the way the medical profession, and society as a whole, thinks and talks about death. “Sadly”, she tells me, “my dad at 37 got pancreatic cancer and then died when he was 40.” Sallnow was 10 years old when she saw her father die at home. She describes what happened next in a matter-of-fact way. It is heartbreaking to hear: “I remember going into school…and teachers being so sympathetic, but it being too big, the grief being too big for them to understand it or to almost want to engage with. People just said, ‘If you feel too upset and you need to cry, go and do that in the library.’” One might expect this story to end with Sallnow choosing to focus her career on curing disease, but instead she decided to concentrate on death and bereavement. This decision lies partly in Sallnow's profound sense of empathy and her belief in community; certainly in person, she is exceptionally warm, friendly, and open. She realised that while her own grief was personal to her, the experience of grief was a common, and commonly ignored, part of everyone's life . “What happened to me was obviously very early, but it was a normal event”, she says. “Grief is something that is universal…we will all face this, and everyone will be bereaved and will grieve at different points.”

Sallnow pursued her personal mission with remarkable drive. She started her medical studies in the UK at Emmanuel College, University of Cambridge, in the late 1990s, and in her third year researched children's perceptions of death, revealing unexpected depths of understanding. It was the first example of what she describes as the “gentle disruption” that has characterised her career. During her specialist training in palliative care, however, she risked disillusionment. “I had this big dream. I’d held it up as the ideal demonstration of a therapeutic relationship, of normalising these universal processes…and I was so disappointed.” In search of a form of end-of-life practice that went beyond setting up syringe drivers, Sallnow went to Kerala, India, in the 2000s, to learn about the community-based model of end-of-life care under the mentorship of Suresh Kumar, Director of the Institute of Palliative Medicine. Kerala represented “an absolutely enormous paradigm shift”. She recalls how Kumar told her that “we in medicine view life-limiting problems as medical problems with social components”, whereas these are actually “social experiences with medical components”. You need opioids for cancer-related pain; but Sallnow tells me that is not the entirety of end-of-life care, any more than epidurals are the entirety of the experience of childbirth.

The UK, however, was not ready to receive the message. “People said it was utopian blue-sky thinking”, she says. So Sallnow set about proving them wrong, helping to build Public Health Palliative Care International (PHPCI), an international association of people working in palliative care, writing a book, and putting together a PhD project translating the model from Kerala to East London. The Compassionate Neighbours project, as it is now known, currently runs across multiple sites in the UK. Her work for the Lancet Commission, which is to reconvene, has also “been very powerful”, she says. “It has created a space. It's given it a legitimisation, and many people have said to me what they value most about this is it has given the legitimacy and opportunity to take it to their hospital directors, to their government, to their masters committee, to say we’re going to talk about this. So I think it's opened doors.”

When I ask Sallnow what she makes of the current debate on assisted dying in the UK, she points to the bigger picture. “Who would be dying through that way?…We know from other areas that it's likely to be people who’ve got high health literacy, who’ve enjoyed really good access to health-care services, have trust in health-care services, and are ready to say ‘I’ve had enough health care’”, she comments. It appears that the end of life is a microcosm of the social challenges of modern-day health care, in which a minority pursue the goal of near-immortality, while others have to fight hard to achieve the minimum of dignity and comfort in life—and, indeed, in death. There are no simple answers, but Sallnow maintains a clear vision: “I want death to be understood, and dying to be understood, as a part of our health…there’ll be times when we need to push it back and try to avoid it, and to build equity and to improve health and wellbeing. But there are other times it needs to be understood…And that's what I’m trying to get. How can we understand death and dying as a part of our wellbeing, not only its failure?”