The modern hospice movement is one of the great humanitarian advances of the last hundred years. The story began shortly after World War II, when a young, devout, Anglican medical social worker named Cecily Saunders befriended a Jewish émigré named David Tasma. Tasma had escaped the Warsaw Ghetto only to be dying at age 40 in a London hospital. He was alone in the world, and Saunders made a special point to visit with him every day. Their friendship changed how we medically treat—and perhaps even more importantly, perceive—people who are dying.

I was honored to interview Dame Cecily (as she is affectionately known in the United Kingdom) in 1998 while researching my book Culture of Death.¹ In reflecting on her friendship with Tasma, she recalled experiencing an epiphany: “I realized that we needed not only better pain control but better overall care. People needed the space to be themselves. I coined the term ‘total pain,’ from my understanding that dying people have physical, spiritual, psychological, and social pain that must be treated. I have been working on that ever since.”² (Tasma bequeathed Saunders 500 pounds to begin her work, telling her, “I will be a window in your home.” Saunders told me, her eyes moistening, “It took me 19 years to build the home around that window.”)³

Urged on by her deep desire to help dying people, Saunders enrolled in medical school at the age of 33, this at a time when there were still few women doctors. Upon entering practice, she focused on the care of dying patients, which was not then a specialty. She obtained a fellowship in palliative research and began work in a hospice run by nuns, where pain control was unevenly applied—a nearly universal problem at the time, causing much unnecessary misery. That was when Saunders conceived of putting patients on a regular pain control schedule, which, in her words, “was like waving a wand over the situation.”⁴

Saunders’ faith-inspired commitment to dying people pushed her forcefully toward founding a hospice based on her concepts. She became an activist, energetically raising money for the new project, and in the process raising the consciousness of the medical establishment. Saunders’ initial idea was for St. Christopher’s Hospice to be a “sequestered religious community solely concerned with caring for the dying.” But the idea soon expanded from a strict religious vision into a broader secular application.

By the early 1970s, Saunders launched the modern hospice movement, beginning in the United Kingdom with her founding of St. Christopher’s; soon, the new approach to caring for the dying expanded to the United States and much of the West. The movement grew exponentially, and for a time hospice was covered widely in the media.

Hospice Services

Before the emergence of the modern hospice movement, dying had become institutionalized, with most deaths occurring in sterile hospital rooms rather than in one’s own bed. It was almost as if people died hidden away in dark corners. Too many dying people became isolated, adding to the difficulty of their circumstances.

Thanks to hospice, that kind of backward thinking abated as patients increasingly benefited from the multidisciplinary approach championed by Saunders. People came to realize that hospice isn’t about dying but about living to the fullest extent possible during one’s final weeks and months. The “multidisciplinary” care provided by a hospice facility or in the home includes:

• Physician supervision: Hospice must be prescribed by a physician. Once the patient is admitted to the program, the hospice medical director becomes the anchor, establishing a plan of care and supervising its implementation. When hospice began, these doctors were often retired from other specialties. But as the hospice movement thrived, providing this care became a certified medical specialty.⁵

• Nursing Services: The person in most direct contact with the patient and family is the hospice nurse, who visits the patient regularly and makes adjustments as needed in medications or the provision of other interventions. This nurse specializes in alleviating symptoms and coordinates care under the supervision of the medical director.

• Social Services: Hospice care also includes non-medical interventions from, for example, social workers who can advise about benefits and chaplains who can provide spiritual support to the patient and family. As originally established by Saunders, it also included suicide prevention interventions if needed.

• Home Care Aides: Caring for a dying patient can be grueling. So, the hospice will provide home care aides for such compassionate services as bathing, rubbing cream on dry skin, and checking sanitary issues.

• Volunteers: Members of the community can help in this important endeavor by becoming hospice volunteers, who help with a variety of different tasks, depending on each individual circumstance. When I was a volunteer in the late 1990s, I might clean house, spend hours conversing with the patient, provide transportation to and from doctors, and the like. Volunteers can also be the eyes and ears of the multidisciplinary team, since patients and families may be more candid about their circumstances with a lay person than with professionals.

Hospice care has become so ubiquitous that most readers probably have some experience of the beneficent services it offers. Both my parents died while in hospice care, and their experiences—as I will relate briefly below—were nothing but exemplary.

Hospice Under Threat

But now the hospice movement has run into serious trouble. These days, after I make a speech or when I appear on talk radio, it has become common for people to tell me horror stories of poor-performing hospices. Some even believe that hospices are more concerned with patients dying sooner rather than with providing the level of care that Saunders pioneered and championed. Some have even come to think that hospice represents an “abandon hope, all ye who enter here” approach to care, when it should offer just the opposite. Saunders would be appalled.

And I am not just hearing anecdotes from patients and their families. My friend Ira Byock, the great palliative care doctor and author of Dying Well,6 warned in a supremely important 2022 essay that “hospice is gravely ill.”⁷ He identified several systematic deficiencies that he believes undermine the crucial succor that hospice is designed to offer.

Primarily, Byock worried that the increase in for-profit hospices too often does not result in the best and most humane care for dying people. He wrote:

Today’s publicly traded and private equity-owned hospice companies have a competing priority: delivering a financial return on their shareholders’ investments . . . . Their aggressive tactics for recruiting patients, the higher salaries they pay, and their bare bones “high efficiency” clinical practices influence the business environment for all hospice providers.⁸

In other words, Byock believes that the proper application of hospice philosophy has been undercut by an atmosphere of intense focus on the bottom line rather than on the individual needs of patients and families.

Byock also warned about fraud and abuse seeping into the industry, for which he insisted there must be institutional “zero tolerance.” In addition, he lamented that the integration of palliative care within the American health system had stalled, despite the sector demonstrating that quality care for seriously ill and dying people is both feasible and affordable.⁹

Byock wasn’t alone in expressing concern. After his essay was published, an exposé in the New Yorker reported that for-profit hospices had come to represent 70 percent of the field in 2019, with many companies owned by non-medical professionals with little expertise in caring for patients. Some are even owned by private equity firms:

Under the daily-payment structure, a small hospice that bills for just twenty patients at the basic rate can take in more than a million dollars a year. A large hospice billing for thousands of patients can take in hundreds of millions. Those federal payments are distributed in what is essentially an honor system. Although the government occa-sionally requests more information from billers, it generally trusts that providers will submit accurate claims for payment—a model that critics deride as “pay and chase.”

That consolidation and lack of accountability adversely impact care:

For-profit hospices have been found to have higher rates of no-shows and substanti-ated complaints than their nonprofit counterparts, and to disproportionately discharge patients alive when they approach Medicare’s reimbursement limit.¹⁰

Did Byock’s essay and the New Yorker exposé bring about needed reform? Apparently not. The next year, Byock again prodded the industry that he once led. His second essay noted that the first reaction by institutional leaders to the earlier expressed concerns was defensive rather than proactively engaged:

As a founding member of both AAHPM and NHPCO, I’m a reluctant public critic. However, patient safety concerns demand public scrutiny. Rather than responding to this public health crisis, the hospice industry is managing this as a public relations crisis. Until national hospice associations and their for-profit provider members ac-knowledge their part in tolerating shoddy business and clinical practices, their lobby-ing efforts can be seen primarily as efforts to preserve the status quo.¹¹

I last spoke with Byock about his concerns on my Humanize podcast in 2025. I asked him if he had seen any improvement since his 2023 essay and whether the industry had established, for example, an accreditation system to allow consumers to separate the hospice wheat from the chaff. Alas, no. He told me:

All of these years, the industry has never stood up and done that.  The public needs to be able to separate not only the good from the bad but the excellent from the mediocre What we have today are markets that aren’t working because the criteria for excellence have been obscured. The public doesn’t know. Instead, competition happens through corporate deals and bargains and discounts and affiliations that leave out com-petition based on quality that would help drive the healthcare industry in general and certainly my own field of hospice and palliative care toward demanding excellence.¹²

Since then, Byock has continued his push for reform. In June of 2025, he authored an extensive white paper in Palliative Medicine Reports,¹³ noting that among 4500 hospices, nearly 20 percent had one or more serious deficiencies and over 300 were “poor performers.” In that essay, he offered a specific plan for reform, including the following four remedials:

• Publish clinical and programmatic standards. Standards provide the basis for meaningful evaluation of quality and accountability in hospice and palliative care. Without operational specificity—including minimum staffing ratios, training hours, and response times—existing published guidelines fall short of what this strategy requires.

• Make meaningful data readily available to the public. Data and measurement allow assessment of performance against published standards. Accessible, reliable, and user-friendly public-facing data enable patients, referring providers, and payers to make informed choices.

• Drive competition based on quality. Reorienting market success to align with measured quality of services and patient-family experience is essential. For-profit and nonprofit providers alike must compete by delivering demonstrably excellent care.

• Promote the authentic hospice experience: The field is distinguished by intentionally fostering well-being for the people it serves. In embracing this distinctive identity, hospice and palliative care can establish itself as an essential service for people with serious illness.

To which I would add: Allow people who enter hospice to also receive curative or life-extending treatment. Do that, studies have shown, and less money will be spent on end-of-life care even as more people enter hospice to receive its many benefits.¹⁴

The Threat to Hospice Posed by Assisted Suicide

There is another threat to the movement that receives too little attention. For the past several decades, euthanasia/assisted-suicide ideologues have worked overtime to conflate hospice, palliative care, and the medical alleviation of pain and other distressing symptoms of serious illness with intentionally ending the life of the patient. They have strived—too often successfully—to redefine homicide or the prescription of poison as “medical treatment” they euphemistically call MAID (medical aid in dying). The sub-version of Saunders’ philosophy posed by the legalization and normalization of assisted suicide cannot be overstated.

Helping to kill a dying patient runs directly counter to Saunders’ under-standing that suicide prevention, when needed, is crucial to fulfilling a hospice’s call to value the lives and equal intrinsic dignity of each patient until the moment of natural death. Indeed, when I was trained as a hospice volunteer, my instructor pounded into my head the importance of reporting to the hospice team any suicide threats or yearnings my patients might express so they could provide the patient with proper interventions.

But assisted-suicide advocates are determined to transform hospice into “hemlock” (as one advocate once put it), a facilitator of suicide rather than a preventer of self-killing. They believe that access to lethal prescriptions should be considered merely another menu item available for dying patients (and ultimately others) to control the time and manner of their deaths. Alas, today some suicidal hospice patients (in states where assisted suicide is legal) are facilitated in hastening their deaths rather than receiving prevention. This conflation has been catastrophic. Advocacy for—and the increasing legalization of—assisted suicide has supplanted hospice as the apple of the media’s eye. Partly this is because the media has become so besotted with “aid in dying” propaganda that there is little room left to tell good hospice stories. But I also blame institutional hospice organizations, which pretend that assisted suicide isn’t a mortal threat to the movement’s core philosophy. As a consequence of what can fairly be called institutional cowardice—aided and abetted by philosophical confusion—in most cases all we hear from hospice organizations about facilitated death is the proverbial sound of silence. Alas, some—though certainly not all—hospices even cooperate in helping patients kill themselves.¹⁵

Conclusion

As I write this essay, I reflect upon the death of my father in 1984. Dad fought the good fight against colon cancer for about two years until the day he was sitting on a hospital bed contemplating a bile drainage bag that doc-tors had inserted to prevent jaundice. Dad looked at the bag taped to his inner thigh and sighed deeply as his shoulders sagged. He looked up at me with an expression I had never seen before. That was it, I knew. Dad had made a momentous decision: His fight to stay alive was over.

But that was far from the end of the story. Just because dad was dying did not mean his life was over. We shifted emphasis from cure and/or life prolongation to comfort, dignity, and peace. That meant hospice, which then was still a relatively novel concept.

Dad benefited tremendously from hospice care. His last several months were peacefully pain free. He spent hours sitting on a bench in the back-yard of the home in which I was raised contemplating life and surveying his beloved cactus garden. He was cared for well and compassionately by my mother and by dedicated hospice professionals, eventually slipping away peacefully in the Wadsworth Veterans Hospital hospice unit.

Fast forward to 2016. My mother was dying from Alzheimer’s disease and its ancillary effects. My wife and I took her into our home and were supported in caring for her by dedicated compassionate hospice professionals. I will never forget one of the nurses, who was from Africa, calling my mother “Miss Leona” in a cheerful voice as he examined her. Mom was thrilled with the attention. When she passed, the hospice nurse came to my home at 3:00 a.m. to certify the death so that we could begin making mom’s final arrangements. My family is not alone. The good that hospice, properly administered, has brought to the world cannot be quantified. The pain it has prevented cannot be measured. If we are to continue to value people who are dying and of-fer them the best of care, the hospice sector needs to defend itself from the threats posed by the assisted suicide movement and an overly money-driven attitude that Byock and others now warn has supplanted the original focus of hospice in some programs.

We had better hop to it. Treating “total pain” takes time, patience, love, and an unalterable commitment to the inherent value of each patient’s life. More precisely, hospice supports life with dignity for its patients. Many of us and those we love will one day require these services. That makes hospice a noble cause and a moral necessity worth defending!

NOTES

1. Wesley J. Smith, Culture of Death: The Assault on Medical Ethics in America (San Francisco, Encounter Books, 2000, reissued and revised as Culture of Death: The Age of “Do Harm” Medicine in 2016, New York, Encounter Books).

2. Dame Cicely Saunders, Interview with Author, December 8, 1998.

3. Id.

4. Id.

5. See, American Academy of Hospice and Palliative Medicine, Home | AAHPM and Hospice Medical Director Certification Board, HMDCB | Hospice Medical Director Certification Board.

6. Ira R. Byock, Dying Well: Peace and Possibilities at the End of Life (New York, Riverhead Books, 1998). https://tinyurl.com/4r3jeb7r

7. Ira Byock, “Hospice Care Needs Saving,” STAT, December 14, 2022. https://www.statnews. com/2022/12/14/hospice-care-needs-saving/

8. Id.

9. See for example, Arthur Caplan and Wesley J. Smith, “Assisted Suicide Compromise,” USAToday, November 13, 2014. https://www.usatoday.com/story/opinion/2014/11/13/assisted-suicide-compromise-hospice-hope-treatment-column/18994071/

10. Ava Kofman, “How Hospice Became a For-Profit Hustle,” New Yorker, November 28, 2022. https://www.newyorker.com/magazine/2022/12/05/how-hospice-became-a-for-profit-hustle?_ sp=f0f03a5b-737c-4fef-a3b4-03606c8e4ee5.1756488814851

11. Ira Byock, “The Hospice Industry Needs Major Reforms: It Should Start with Apologies,” STAT, August 22, 2023. https://www.statnews.com/2023/08/22/hospice-care-industry-reform-apologies/

12. Wesley J. Smith, “Ira Byock M.D. on the Crisis in Hospice Care,” Humanize podcast, Season 4, Episode 10, February 10, 2025. https://humanize.today/podcast/ira-byock-m-d-on-the-crisis-in-hospice-care/

13. Ira Byock, “A Strategic Path Forward for Hospice and Palliative Care: A White Paper on the Potential Future of the Field,” Palliative Medicine Reports, June 4, 2025. https://www.liebertpub. com/doi/10.1089/pmr.2025.0030

14. Caplan and Smith, “Compromise,” Supra.

15. For a more detailed discussion, see Wesley J. Smith, “Hospice, Defend Yourself!,” First Things, February 5, 2015. https://firstthings.com/hospice-defend-yourself/

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Original Bio:

Wesley J. Smith is a senior fellow at the Discovery Institute’s Center on Human Exceptionalism and a consultant to the Patients Rights Council. In May 2004, Smith was named one of the nation’s premier thinkers in bioengineering by the National Journal because of his work in bioethics. In 2008, the Human Life Foundation named him a Great Defender of Life.