End-of-life care; Equity; Health systems; Public health; Social contract; Systems thinking; Health (social science); Public Health, Environmental and Occupational Health; Economics and Econometrics; Political Science and International Relations
Abstract :
[en] End-of-life (EOL) care is a universal yet deeply unequal experience across Europe, revealing persistent gaps between people’s preferences and health system delivery. Despite strong evidence that most individuals wish to die at home or in familiar surroundings, EOL care remains overly medicalised, hospital-centred, and socially stratified, with significant socioeconomic inequalities in access to palliative care that have widened since the COVID-19 pandemic. This commentary argues that EOL care constitutes a critical test of the social contract and should be understood as a core health system issue rather than a marginal or purely clinical concern. Drawing on European policy debates, comparative evidence, and examples of public health and democratic innovations—including Compassionate Communities and citizen deliberation processes—we frame EOL care as a systemic, relational, and societal challenge. We highlight the importance of death literacy, community engagement, and participatory governance in rebalancing responsibility for dying between health systems, communities, and society at large. We conclude by identifying key policy priorities for integrating EOL care across health systems, strengthening equity and solidarity, and reframing EOL care as a shared societal obligation grounded in dignity, compassion, and collective responsibility.
Disciplines :
Public health, health care sciences & services
Author, co-author :
Rajan, Dheepa; European Observatory on Health Systems and Policies, Brussels, Belgium
Bodson, Oriane ; Université de Liège - ULiège > Santé publique : de la Biostatistique à la Promotion de la Santé
Sillitti, Paola; Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland ; Lausanne University Hospital (CHUV), Lausanne, Switzerland
Sallnow, Libby; Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
Moccia, Francesca; Cittadinanzattiva, Rome, Italy
Ilinca, Stefania; World Health Organization, Regional Office for Europe, Copenhagen, Denmark
Berriau, Nathalie; Citizen Convention on End-of-Life Care, Association “Les 184”, France
Marsico, Giovanna; French Ministry of Health, Paris, France
Language :
English
Title :
End-of-life care and the social contract: A European reckoning?
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