Author:
Dr Cajetan Skowronski, ST6 in Geriatric and General Internal Medicine, Sussex.
“The awful, terrible act of his dying was, he could see, reduced by those about him to the level of a casual, unpleasant, and almost indecorous incident (as if someone entered a drawing room diffusing an unpleasant odour)…He saw that no one felt for him, because no one even wished to grasp his position. Only Gerasim recognized it and pitied him.”
– The Death of Ivan Ilyich, Leo Tolstoy.
Disgust is one of the basic emotions common to all human beings, universally recognizable by the facial grimace and sensation of nausea which transcends all languages and cultures (1). Experiencing disgust is well known by psychologists to alter behaviour. In public health campaigns, disgust is deployed with great effect to discourage dangerous behaviour. Buying cigarettes is no longer a choice between the seductive packaging of glamorous brands, but rather, a choice between a bland box with a photo of an emphysematous lung or a necrotic tumour of the neck.
The evolutionary reason for disgust is thought to be the avoidance of infectious pathogens by avoiding smells and sights we associate with sickness. So the source of our employment – disease – can be fairly described as disgusting.
For nearly two years, parliament has been considering the question of whether the NHS and hospices should provide lethal doses of drugs to patients as so-called “Assisted Dying”. This would redefine what is currently the crime of assisted suicide as a form of therapy.
I was struck how often, wittingly or not, proponents of a change in the law employed the language of disgust to justify the compassionate poisoning of patients. Many MPs reported only one or two personal experiences dealing with death, but based their decision on how to vote on these cases, as well as the most horrific examples of bad deaths submitted to them by constituents, or in the media. Drowning in your own faecal vomit was a mode of death frequently referenced by MPs in favour of assisted suicide. It is questionable whether this is even theoretically possible (2), but if by faecal vomit they actually mean gastric secretions in a bowel obstruction, there are well established palliative interventions to control this. Kit Malthouse MP, a champion of this faecal-drowning image, summarised his disgust in a House of Commons debate: “The deathbed for far too many is a place of misery, torture, degradation, a reign of blood and vomit and tears. I see no compassion and beauty in that, only profound human suffering.”
The youngest MPs were far more likely to vote Aye to Assisted Dying, with 72% of millennials voting in favour at Second Reading. MPs representing poorer communities with higher burdens of disease and disability were more likely than those representing richer, healthier constituencies, to vote no.
Amongst doctors, specialists who are most involved in directly caring for the terminally ill and dying are the most likely to be opposed to assisted suicide, while those whose jobs are most removed from direct contact with these patients are most likely to be in favour (3).
Your likelihood to support assisted suicide is inversely proportionate to your exposure to frail and dying people. Why is this?
I spoke to several MPs before the Second Reading of the Assisted Dying bill. They all happened to be in favour. They also happened to be young and healthy. One MP described the death of a relative in quite normal circumstances, but was personally shocked at seeing how the relative had changed from physically robust to weak and frail since he had last seen them. This weakness and dependence, the MP explained, meant he felt his relative was lacking in dignity. He wished there had been a way the relative could have avoided becoming this frail, even though he acknowledged the relative in question would never have personally wanted assisted suicide.
I could not help thinking that “lacking in dignity” was actually a polite way of saying “disgusting”.
The horrible truth is that if you are young and healthy and spend all your time with other young and healthy people, then being confronted suddenly with frailty and disease, and proximity to death, usually provokes feelings of disgust. This primordial instinct is now turbocharged by how sealed off we are from the elderly and the infirm in our atomised society. It can take months or even years of caring for, touching, smelling and seeing the weak and the frail to overcome this natural sense of disgust.
There is a parallel training in healthcare, which we have all been through. Next to the steady accumulation of knowledge and skill is the gradual acclimatisation to disgust. Very few enter medical school or nursing college able to work calmly and professionally in the presence of a disfiguring or malodorous pathology – even if we are able to put on a brave face and make a dark joke on our first trip to the anatomy lab.
But with time the patient’s pathology retreats, and the patient as a person comes to the fore.
This stepwise desensitization is necessary for us to do our job well. Not just technically, while performing a procedure, or taking an accurate history. But also as holistic care-givers, by recognising and affirming the dignity of our patients, whatever their physical or psychological condition.
Beyond disgust at the physical experience of the dying body, there is, of course, a deeper disgust at the very concept of death. Death itself is now hidden in a way that is unprecedented in human history. The vast majority of bodies are cremated. The open coffin wake or funeral is a thing of the past. Children are frequently excluded from deathbeds and funerals. Our society fears and despises death so much that we are now contemplating killing to try to get the better of it.
There is no scientific answer as to whether the suicide of the terminally ill is a good thing or a great wickedness. Science is a tool and not a master here. But we can look to literature for some useful reflections. We can join in the spirit of Dorian Gray, who in his disgust at ageing and death became morally hideous under a veneer of youth and beauty. Or we can follow the humble example of Gerasim, the peasant servant who alone served Ivan Ilyich well in his dying days, by accompanying and comforting his poor master, to the very end.
Social Media: X @tradskowronski
References:
- Hadjittofi M, Gleeson K, Arber A. The experience of disgust by healthcare professionals: A literature review. International Journal of Nursing Studies. 2020.
- Duffy, T. “Faecal vomiting” – a case of frequently mentioned, but rarely seen. BMJ Supportive & Palliative Care. 2025
- Kantar. BMA Survey on Physician-Assisted Dying Report. 2020.