Richard Smith: Four future scenarios of death and dying

The future is unpredictable. The unexpected happens often and can have a major impact. Nevertheless, some thought of how the future might look is important in preparing for it. Scenarios are one way of doing this and were developed after the wholly unforeseen oil shock of 1974. Scenarios are not predictions of the future, but rather sketches of plausible futures with the limits of plausibility set wide. They are not what people would like to happen, but rather what might happen. They have been used to think about the future of South Africa after Apartheid, the NHS, and scientific publishing. They are in many ways devices for thinking about the present, recognising things that will be important whatever the future brings.

Elaborate methods can be used to produce scenarios, but there is value in simply shared imaginings. I have imagined here four scenarios of the future of death and dying. Famously, the future is already here, but not evenly distributed, and that is true of these four scenarios.

“Immortality” and inequality

Medicine is successful with extending life but at great cost, increasing global inequality

Medical research uses genetics, big data, nanotechnology, artificial intelligence, and other methods to find ways to increase the length of life considerably. At the same private companies develop ways of “downloading brains” to allow some people to achieve “immortality.” These methods are extremely expensive, making them available to only a few. The very rich can access them and live much longer, while the poor, as now, have much shorter lives.

Climate response

The world and end of life care become much more equal

The climate crisis causes people to recognise our global interdependence and the rich to accept reducing their carbon consumption and access to expensive health care. Resources—financial and health care workers—shift from rich to poorer countries. The world becomes more equal, and the minimum package of palliative care described by the Lancet Commission on Palliative Care and Pain Relief becomes available to all while end of life care in rich countries becomes less technical and more human.


Families and communities become more important and health care simply supportive in managing dying and death

A growing number of people become unhappy with the increasing medicalisation of end of life care and the lack of meaning around death and dying. They take back control from the health establishment, change laws, set the agenda, and run end of life programmes. These developments are an extension of programmes—like that in Kerala and Compassionate Neighbours, Communities, and Cities—that have developed to increase the capacity of families, communities, and volunteers to manage death and dying. Health care remains important but plays a supportive role.

Assisted dying spreads 

Assisted dying becomes a component of universal health care

Assisted dying spreads to all almost all high income countries and many low and middle income countries. It is available not only to those judged to be near the end of life but all those with unbearable suffering and those developing dementia. It is tightly regulated but provided by many health care professionals, including those working in palliative care. In most countries some 10% of people die this way, but the range is from 1% to 25%.

Richard Smith was the editor of The BMJ until 2004.

The Lancet Commission on the Value of Death welcomes reactions to these scenarios and ideas on alternative scenarios.