Archbishop Tutu’s life-long courage to speak out on the issues he is outraged about, or that he feels need urgent attention, is his gift not only to South Africa but also to the world. Tutu is keenly aware of his global standing and wields his influence as a thought leader judiciously, sometimes ferociously, on all issues pertaining to human dignity: apartheid, HIV/Aids policies, homophobia, access to sustainable energy, climate change, the incarceration of black people in the United States, the recognition of gay marriage in the Anglican church. And now, ‘closer to my end than my beginning,’ as he puts it, he is applying his moral clarity to questions of life and death.

The outcome of our last conversation was an editorial published in The Guardian, timed to coincide with the bill for assisted dying that was being heard in the British House of Lords on July 18, 2014. July 18 also happened to be the date of Mandela’s birthday – and that specific July 18 was the first since Mandela’s death eight months earlier.

In that powerful piece, the Archbishop not only voiced his support for a UK policy change on people having the legal right to choose death accelerated by medical narcotic assistance, but he also spoke about the indignity he felt accompanied Mandela’s death. The Archbishop honored his good friend by sharing his heartfelt anger at the manner of his dying and called strongly for new policies that would allow people to die with more dignity.

In our discussion, the Archbishop voiced how appalled he was to hear that politicians arrived without forewarning at Mandela’s private home for a photo shoot when he was very ill. He said as he watched the TV footage he noted his friend Madiba’s facial expression was one of threatening thunder and that he was silent throughout.

That was April 2013: a few weeks later Mandela suffered cardiac arrest. Legal documents issued later that year referred to Mandela being in a permanent vegetative state with no chance of return to cognitive engagement. From this time, Mandela’s breathing was assisted with an oxygen pipe inserted into the trachea and he was fed intravenously. Mandela officially died eight months later in December 2013.

With our earlier conversation about Mandela on my mind, it took me a while to find the right words to ask:

Archbishop, in my book I want to write that dying is another area of personal leadership, the ultimate act. And I’d venture to say that Joe and Madiba, for all their inspirational leadership qualities, iconic heroes in the struggle against apartheid, neither prepared well for death.

I don’t know how many people I might offend. But my observation is that death is difficult and we who are left behind, we grieve, we suffer. It seems to me that there is even more suffering because of the conversations that people haven’t had. But if my book says dying is your final act of personal leadership, and it’s one which Madiba didn’t get right, will I be on the receiving end of an angry response?

The Archbishop responded:

You have identified areas that have been taboos for a very long time and I think you will get responses, angry responses, because most of it has been taboo. You must get on your suit of armor, put on your tin hat, your steel helmet, and say, well, yes, and engage. This is the lot of anyone who sticks their neck out. This taboo about not talking about dying, like so many other taboos, it is not rational. It needs to be challenged. It is a heck of a lot better to know, to accept that dying is as natural as growing old. Obviously, the anguish happens when someone dies young or dies violently. But it ought to be the case that, as I have been saying, that dying is part of life.

You know how people look at you and they say ‘Oh, you look so young’ and imagine that they have given you a compliment. And I say, you know, I have been young, I have been middle-aged, and now I am more old. And that’s quite right because if we were to remain young or even middle-aged, our world would not be able to support us. And it’s wonderful! How would I have become a grandfather if I remained 17 years of age? But people – look at the trouble they go to! – to hide the fact that they‘ve got wrinkles and grey hair.

The Archbishop had recently been in and out of hospital; through his prostate cancer, this body was voicing its fragility and challenging any denial. I asked how he was feeling about his own dying, considering his own legacy of personal leadership.

He reflected a little and then answered, quizzically at first:

Yes. I’ve been wondering how I’m feeling. Am I fearful? Is there some element of anxiety about what’s next? What happens at the end, before the next beginning? I used to say they must make sure I’m quite dead before they put me in the coffin and in a grave. I don’t want to asphyxiate, you know! I do consider it an incredible privilege of having aged. I will be 84 on my next birthday and on at least two occasions the medical prognosis was that I was about to kick the bucket. I think I told you how my father bought the wood for making my coffin and the black cloth for hanging. I ended up with a lame hand – it was polio.

Later, there came a point where I was hemorrhaging and hospitalized. Each time I coughed, a flood of blood would come out. I had noticed – I was about 13 or 14 then – that without exception people who coughed like that ended up being wheeled out of the ward. I expected the same for myself. One time I went into the bathroom and had another coughing attack when it seemed like gallons of blood were coming out. And I sat there and I said to God, ‘If it means that I have to die, okay.’ And I was surprised at the peace and calm that came over me.

I asked Archbishop Tutu if having been in a state of calm acceptance of the prospect of dying in his early teens did he stay that way? What happened as his life unfolded?  He reflected that while he was surprised at his teenage calmness, in adulthood he got a little more anxious. ‘Part of it is worry about what’s going to happen to your family – your children and your wife.’

The clock moved to 10:30 that Thursday morning, the designated time for the Archbishop to have his weekly tea with all the office staff of the Desmond and Leah Tutu Legacy Foundation. And today one person has a birthday; today there will be cake. We can’t delay.

‘You know Helena? No? Well she and I are discussing the very important subject of dying,’ he told those who had gathered.

I heard some audibly sharp intakes of breath in the room. The Arch had been frail and close to dying a couple of times in the last few months and they wondered how he could be so at ease with talking about this subject matter when they were avoiding speaking of it. But the Archbishop was persistent. He drew people out. Tea with birthday cake became a mini workshop.

One person, Varinia, spoke of how important it would be to have a book that prompts conversation, how she personally would welcome this in her life. She talked of her grandfather’s dying and how her parents were paralyzed by shock and she had to take over all the arrangements. She described her grandfather, a tall, broad-shouldered man of farming stock. She was asked to choose a coffin.

‘But they are all too short,’ she said.

‘No, the size is standard,’ replied the owner of the funeral home, ‘we just break the legs.’

Varinia began to cry as she said these words out loud. She’d never shared this story with anyone, and the feelings of sadness had continued even with the passage of time.

My friend Gonda, deputy dean at the University of Cape Town Medical school later confirmed that coffins come in a standard size, and that it was standard practice to break limbs or shoulders. Joe was big, she commented, ‘They probably had to break his legs to fit him inside his coffin.’

The legacy of Desmond Tutu, Nobel Peace Prize Laureate, is deep. And he’s still adding to it. He is edging down the road towards his life’s end, sometimes tapping his way there with his walking stick, other times using a wheelchair.

For the occasion of his 85^th birthday in October of 2016, he made a video for the US advocacy organization Compassion and Choices – the same group which had helped to spread the Brittany Maynard story, which tipped the scales toward legalizing assisted dying in California, Quebec and Colombia. At the same time, an article published in The Washington Post confirmed his belief that people should have choice about how they die, including medically-assisted dying.

Just as I have argued firmly for compassion and fairness in life, I believe that terminally ill people should be treated with the same fairness when it comes to their deaths. Dying people should have the right to choose how and when they leave Mother Earth. I believe that alongside the wonderful palliative care that exists, their choices should include a dignified assisted death. I have prepared for my death and have made it clear that I do not wish to be kept alive at all costs. I hope I am treated with compassion and allowed to pass on to the next phase of life’s journey in the manner of my choice.

The words ‘natural death’ have no ring of truth for the Archbishop’s situation; nothing is natural about his continued living. He’s the beneficiary of the finest medical interventions available.

The day after the article ran, I opened my emails to find one which had just arrived. The CEO of the Hospice Palliative Care Association of South Africa, Liz Gwyther, had sent out this strongly-worded press statement.

Archbishop Tutu is wrong or misinformed about the life or death issue of euthanasia. The right to live and to die in dignity is one of the basic principles of palliative care… We know that with palliative care people do not have to ‘endure terrible pain and suffering.’ Palliative care can control pain and enable people to live well, in comfort and dignity until the moment of their natural death… We also know that people who request euthanasia do so because of despair and a gap in the care they are receiving. I would like to have a conversation with Archbishop Tutu to discover his understanding of end-of-life care and what has led him to this philosophy of despair.

Natural death? there’s nothing natural about using doses of painkillers for sedation with their side effect of coma and a possibly hastened death – even if this is not the primary intent.

Philosophy of despair? Archbishop Tutu? The man who cackles with laughter as he drinks his hot chocolate at the Friday morning breakfasts and whose latest publication is called The Book of Joy, co-authored with the Dalai Lama?

I was saddened by that press statement. Hospice associations in other parts of the world take a different stance. Ann Jackson spent 20 years as CEO of the Oregon Hospice Association. In 1994, she voted against the public initiative which adopted the Death with Dignity Act. Today, she says, she would vote in favor of physician-assisted dying.

As hospice and palliative care physicians frequently tell their patients, ‘I can promise to manage your pain and symptoms, but I can’t promise to keep you awake.’ Being sedated to the point of a coma is not an acceptable option for most persons whose primary concerns are about losing autonomy, their quality of life, and dignity – as they define dignity.

The major beneficiaries of Oregon’s Death with Dignity Act are those who do not use it to hasten their deaths. Of 25 people who talk to their doctor about a request, one will ingest medication to end his or her life. Hospice workers describe patients as making a request on day 1, qualifying for a prescription on day 15, then tucking their prescription, or their medication… into a safe place. That’s when they can get on with living. They have a plan, just in case.

A week after the 85^th birthday celebration and the release of the controversial video, I sat with Archbishop Tutu in the Wimpy Bar after the cathedral service and asked him how he felt about the negative feedback he’d attracted from some quarters. The Arch laughed, ‘I’ve got my tin hat on. These criticisms don’t faze me. People need to learn to respect choices.’