Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

Markus Zimmerman

Markus is Professor of Moral Theology and Ethics at the University of Fribourg, Switzerland.

A single bed, wiith an unmade colourful duvet stands in the corner of a room. A hoist reaches over it from the corner.

The dying room, Dignitas Clinic, Zurich.

Dignitas.

While countries such as Germany, France or the UK are currently struggling to find a suitable regulation for assisted suicide, their peers in the Netherlands, Canada and Switzerland have years of experience with the controversial medical practice. Even if each state must explore its own ways of dealing with these ethically controversial issues, it is obvious that international experience should not be ignored as they try to find a way forward.

In Switzerland the discussions and challenges surrounding assisted suicide are increasing rather than decreasing. Contrary to the idea that a liberalisation of assisted suicide would lead to fewer debate, tensions and difficulties are increasing. My observation, and thesis, indicates that practices such as assisted suicide cannot be “normalised”, even in the medium and long term.

Developments

In recent years, one to two per cent of all deaths in Switzerland were due to assisted suicide. From an overall perspective, this practice is therefore still a marginal phenomenon. However, a look at the total number of assisted suicides per year gives a different impression, as this has increased more than fivefold in the years between 2008 and 2020, from an initial 253 to 1,251 deaths per year, a rising trend. The cause of death statistics for Switzerland only include those cases of assisted suicide in which persons resident in Switzerland were involved and the death was reported to the authorities. According to the Swiss Federal Statistical Office, in 2020, it was mainly people over the age of 64 who made use of assisted suicide. Detailed information on the underlying illnesses of the people affected in 2018 shows that about 40 per cent were affected by cancer, just under 12 per cent by diseases of the nervous system, a further 12 per cent by cardiovascular diseases and just over a third by other illnesses, including dementia and depression. There are currently seven right-to-die organisations in Switzerland which play a leading role in a typical assisted suicide procedure. They work closely with doctors who are prepared to prescribe a lethal drug, generally Pentobarbital. The data reflects an ambivalent picture: on the one hand, the proportion of assisted suicide cases is relatively low in relation to all deaths and, for example, in comparison to the large number of people who die in Switzerland in a state of deep sedation until death; on the other hand, the number of assisted suicides in Switzerland has risen sharply in recent years.

Perceptions and assessments

Since the 1990s, the public perception and assessment of assisted suicide in Swiss society has changed from an initially cautious and sceptical attitude towards broad acceptance. While the debates in other countries are characterised by relatively sharp controversies between those in favour and those against, public discourse in Switzerland has been less polarised. There are indications of a certain normalisation of the situation, the strongest sign is that Switzerland has so far refrained from regulating assisted suicide in a separate law. The results of a recently-published study on the opinions of Swiss people over the age of 55 regarding assisted suicide confirm these impressions.: The survey showed that over four-fifths of respondents support legal assisted suicide, almost two-thirds can imagine asking for assisted suicide themselves at some point, and that almost one-third are considering becoming members of an right-to-die organisation in the near future, with one-twentieth of respondents already being members at the time of the survey in 2015. Among people with a higher level of education and older people aged between 65 and 74, approval of assisted suicide and corresponding practices was higher than among less educated, younger and very old people; approval was also significantly lower among religious practitioners.

Sensitive topics

The fact that assisted suicide enjoys broad support in Swiss society as a whole does not mean that there are not difficult and controversial aspects relating to its practice. Relevant topics include, in particular, places of death, authorisation criteria and procedures.

Places of death: Assisted suicide is permitted also for mentally ill persons in psychiatric clinics, but the federal court recommends great caution here and requires two psychiatric expert opinions to ensure that the person willing to die is capable of judgement with regard to the desire to commit suicide. Although assisted suicide for children and adolescents has hardly been an issue in Switzerland to date, the corresponding debates are currently being held in Canada and elsewhere. The question of whether people in prison also have a right to make use of assisted suicide, has been the subject of intense debate in Switzerland for years, with a generally positive response. The question of whether right-to-die organisations should be given access to acute hospitals and nursing homes is still the subject of controversial debate, with regulations varying from hospital to hospital, nursing home to nursing home

Authorisation criteria: With regard to the admission criteria for persons willing to die, the capacity for judgement is at the centre of attention: while the importance of the criterion is undisputed in itself, there is a struggle for reliable standards and procedures to reliably test this criterion. Since the publication of the SAMS ethical guidelines Management of Dying and Death in 2018, the criterion for end of life and, depending on this, that of unbearable suffering have received new attention due to an objection by the Swiss Medical AssociationFMH. While the guidelines are based on the criterion of unbearable suffering, the FMH wants to stick to the near end of life. It is certainly difficult to diagnose the existence of unbearable suffering, as the international debate on the significance and assessment of existential (neither physical nor psychological) suffering shows. This difficulty is illustrated by the debate that has been going on for several years in Switzerland about so-called old-age suicide and the inherent criterion of tiredness of life. At the centre of the dispute is the legally difficult question of whether a doctor is also allowed to prescribe a lethal drug to a healthy person.

Procedures: Here the role of the medical profession and right to die organisations is by far the most important issue. In contrast to the physician-centred models in Belgium, Canada and the Netherlands, the Swiss model of assisted suicide is based on the idea that every person has the right to end their life and may call on the help of any other person to do so. Although the medical profession is usually involved in the process, the management of the procedure is normally the responsibility of a right-to-die organisation. This division of responsibilities is always up for debate when legal regulations are being considered, in which doctors should tend to take the lead in the process due to their professional background. There is also a debate about how and by whom compliance with the authorisation criteria should or could be monitored, whereby it remains to be decided whether this should be carried out before or after the death. At present, a certain amount of monitoring takes place following a suicide, insofar as the authorities investigate the cases afterwards. There is also debate as to whether Pentobarbital is a suitable means of suicide, especially if this barbiturate is not administered intravenously but taken orally; there is no knowledge of how many cases are currently administered intravenously and by whom an infusion is then set up. Last but not least, consideration has already been given to the use of lethal drugs, such as helium gas, which can be obtained over the counter.

Attempts at regulation

Political efforts to regulate assisted suicide in Switzerland in a more nuanced way than today have been made since the 1990s but have remain largely without consequences to date. In relevant judgements by the Federal Supreme Court or in statements by the Federal Department of Justice and Police, reference is regularly made to the ethical guidelines of the SAMS. These are classified as soft law and are therefore not legally binding, even though their content has become the subject of dispute. The National Advisory Commission on Biomedical Ethics (NCE) had already recommended more far-reaching legal regulation in 2005 as part of a detailed opinion on the subject; in the opinion of the NCE at the time, the review of authorisation criteria, a justifiable regulation of assisted suicide for the mentally ill, children and adolescents and state supervision of right-to-die organisations, should be ensured by law. The question is what form a legal regulation can take that grants the medical profession far-reaching powers but at the same time prevents medical paternalism (in favour of or against assisted suicide). From the perspective of Swiss experience, this is “a square circle”: either the doctors retain the final decision on who receives the barbiturate, or official access rules are established, the review of which does not generally require medical expertise.

The outlook

In the short and medium term, it can be assumed that the number of assisted suicides in Switzerland will continue to rise. The coronavirus pandemic and the particular difficulties faced by nursing homes during this time are likely to exacerbate this increase. In view of these expectations and the legislative processes in other European countries, pressure is likely to increase in Switzerland to create a legal regulation. Overall, I think politically it will be important to create a legal regulation, in order to ensure legal equality and legal certainty on the one hand and prevention of abuse and expansion on the other. At the centre of social-ethical reflection is the challenge of learning to deal with the pluralism of different ideas of a good death and to develop and establish alternative models to medically assisted dying. The thesis I mentioned at the beginning is confirmed today: assisted suicide in Switzerland can hardly be normalised; new problems, challenges and demands are constantly arising. Suicide, whether with or without the help of another person, always means an existential transgression that defies normalisation.

Column

Creed

Death & life

Suffering

23 October 2025

4 min read

Dressing up in the dark: what Halloween reveals about our uneasy age

Why Halloween feels darker this year

George Pitcher

George is a visiting fellow at the London School of Economics and an Anglican priest.

Skeleton figurines clothed in Victoria outfits.

Wallace Henry on Unsplash.

Something bothers me about the approach of this years’ All Hallows’ Eve on 31 October and its accompanying night-time Halloween parties, like an irksome background unease at an encroaching darkness behind the childlike cosplay of the event itself.

God knows, there have been infinitely darker years, some of them within living memory. Two world wars, one of them containing the Holocaust and it doesn’t get darker than that. Genocides, such as Rwanda’s, and famines, from China to Russia to Ethiopia. Terrorist atrocities: Munich, Lockerbie, Madrid, 9/11.

Mass murders of children: Dunblane, Peshawar, Sandy Hook, Southport, to name a few in such a grim litany. Harder to imagine, because they’re further away culturally in either time or place, are the great plagues, conflagrations and disasters of history: The Black Death, Indian Ocean tsunami, Hiroshima.

So one wonders if it’s impertinent to feel uneasy about Halloween this year. I suspect it’s the discomfort of something bubbling under and as yet unseen, like unexploded magma or the unbearable tension of a faultline threatening to give way.

To name it is to call out a most fragile world peace – the pretence of a peace in the Middle East that cannot hold; a peace process that hasn’t even started between Russia and neighbouring Ukraine. Both presided over by an American president who at best isn’t up to securing either and, at worst, has zip interest in democratic process and is only in it for himself.

Then there’s apparently unstoppable mass migration, driven by climate change, to western economies already going to hell in policy-free handcarts. The creeping re-growth of nationalism and antisemitism, social media fuelled hatred of refugees, the collapse of trust in institutions of state in the UK’s unwritten constitution, such as the royal family, parliament, the police and the Church. Grooming gangs and trafficked sex-slaves; we’re not in the gloaming of dusk – it sometimes feels like night has fallen.

At what price, then, do we dress our children (and ourselves) as ghouls and witches and demons and make jack o’lanterns to celebrate the dark side at Halloween? It’s the question at the heart of a debate that customarily divides between those of us who say it’s just a bit of fun and we shouldn’t be spoil-sports, against others who warn censoriously about conjuring up the devil, who once abroad will play havoc with those who so foolishly summoned him.

That’s a fairly pointless argument, as the positions just get repeated and that doesn’t get us anywhere. More fruitful may be to examine what the dark side is, what it is we’re conjuring, if anything, and whether it plays any role in what we fear we may be facing, which ranges from the breakdown of the world order, to great wars and, not to put too fine a point on it, an apocalypse.

Stumbling about in the dark, we’re bound to trip over what’s called theodicy – the theological study of how a supposedly all-loving God can tolerate human evil. One of the more recent and most accessible contributions to this school comes from the US journalist and academic Brandon Ambrosino, who imagines the pursuit of theodicy not to be climbing stairs of knowledge, but the descent to a dark basement: “If the living room is where we ask how exactly God moved Trump’s head out of the way of the shooter’s bullet, the basement is where we ask if God caused the bullet to end up in a fire-fighter’s body.”

One of Amrosino’s conclusions is that “evil is not properly a thing… Evil is nothing, literally [his italics]. It is a void in the fabric of God’s creation.” This concept of evil – the dark, as any parent would comfort a child – as empty is appealing. In the dark of that basement, there is nothing there but hope.

This idea of evil as a void, or moral vacuum, is told in the story of a student (not young Albert Einstein, as widely claimed) who demurs when taught that the problem of evil proves the non-existence of God. “Does cold exist?” asks the student. Of course, replies the teacher. But cold is only the absence of energy, which creates heat. Likewise, does darkness exist? Yes, but it has no wavelength, so it is only the absence of light.

What brings the energy of light and heat, like why there is something rather than nothing, is too big a question for now. But it may go some way to addressing the darknesses listed in the first half of this column.

And perhaps it’s a thought to carry into this Halloween. Children dressed as undead phantasms, with Mum’s lipstick tracing blood trickles from their mouths, aren’t joining the dark, but filling what is empty with laughter. And, in doing so, they’re mocking it, which must offer some sort of hope for the future.

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