Article

Assisted dying

Comment

Politics

25 November 2024

7 min read

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.

Review

Culture

Film & TV

Politics

War & peace

18 December 2024

6 min read

Watching Bonhoeffer from below

Does a new biopic capture a compelling and complex character?

David Emerton

David Emerton is Director of St Mellitus College, East Midlands.

Two men, dressed in the style of the 1940s look around shocked.

Jonas Dassler as Dietrich Bonhoeffer.

Angel Studios.

Dietrich Bonhoeffer did not live to see his 40th birthday.

Sentenced to death in a sham trial at Flossenbürg concentration camp, he was stripped naked, led to the gallows, and executed on the direct orders of Adolf Hitler in April 1945, essentially for treason. Ever since, Bonhoeffer’s life and thought has been subject to projects in wish fulfilment. Bonhoeffer has been secularised, liberalised, radicalised, and popularised by people across the religious and political spectrum, and in ways that evidence only casual concern for historical fact and little (or no) comprehension of his literary estate. Most recently and remarkably—in fact, repulsively—Bonhoeffer’s name has even been used by the right-wing Heritage Foundation to denounce the so-called “open-borders activism” and “environmental extremism” of the American Left in its Project 2025 wish list for the presidency of President-elect Donald Trump.

It was with mixed feelings, therefore, that I sat down in a movie theatre in downtown San Diego a few weeks ago to watch the new film Bonhoeffer: Pastor. Spy. Assassin. Released by the Christian production company, Angel Studios, and written and directed by Todd Komarnicki (producer of Elf and writer of Sully), the film (coming to UK cinemas in early 2025) is trailered thus:

“As the world teeters on the brink of annihilation, Dietrich Bonhoeffer is swept into the epicenter of a deadly plot to assassinate Hitler. With his faith and fate at stake, Bonhoeffer must choose between upholding his moral convictions or risking it all to save millions of Jews from genocide. Will his shift from preaching peace to plotting murder alter the course of history or cost him everything?”

The accompanying image has the pacifist-preaching Bonhoeffer holding a gun.

Like any big-screen biopic, Bonhoeffer mixes fact and fiction with a healthy dollop of artistic and cinematic license. This license is of course necessary for the screenwriting art: time needs compressing; biography needs enlivening; peoples’ character needs demonstrating; ultimately, the film needs watching.

There is no doubt that Bonhoeffer spent time at Union Theological Seminary in New York and that whilst there he bemoaned the state of American theology, actively participated in the Abyssinian Baptist Church in Harlem, and became close friends with an African-American student, Frank Fisher.

But learning to play jazz piano at a Harlem nightclub? Being beaten by a racist hotel owner with the butt of a rifle? And becoming an ardent advocate for African-American civil rights?

There is no doubt, too, that, as Hitler rose to power, Bonhoeffer spoke out against the dangers inherent in the Führer concept and that throughout the 1930s he steadfastly critiqued Nazism and national socialist ideology.

But were his words ever these?

“I can’t keep on pretending that praying and teaching is enough.” “Dirty hands ... It’s all that I have to offer.” Or, in response to being asked by his friend and student, Eberhard Bethge, if Hitler is the first evil leader since Scripture was written: “No. But he’s the first one I can stop.”

No one is going to dispute, either, that Bonhoeffer led an underground seminary at Finkenwalde to train future pastors of the Confessing Church in Germany; or that he said, “When Christ calls a man, he bids him come and die.” (Even if, in German, he more literally said, “Every call of Christ leads into death”).

But what is disputable is that (as the film suggests) Finkenwalde was a safe haven from which a plot to assassinate Hitler was launched, and that Bonhoeffer’s most memorable aphorism of Christian discipleship was intended to be spliced (as it is in the film) into footage of a conspirator preparing a suicide bomb.

And Bonhoeffer certainly did join the German Military Intelligence and act as something akin to a double-double-agent. He certainly did pass information about the conspiracy to international church leaders on his travels outside of Germany. He certainly did know about both “Operation Seven” (a plan to smuggle a small group of Jews and Jewish Christians out of Germany to safety in Switzerland), and the planned plot to assassinate Hitler.

But to suggest (as the film does) that Bonhoeffer was central to these plans and personally involved in them, or that he asked Bishop George Bell to lobby Winston Churchill to supply a bomb that the conspirators could use to kill Hitler, is nothing more than highly contentious, even conspiratorial, conjecture.

In a panoply of embellished facts, the film’s final scenes are in equal measure harrowing, arresting, and deeply moving.

Bonhoeffer’s life and thought is obviously compelling.

It is also complex.

Bonhoeffer left behind an array of books, essays, sermons, unfinished manuscripts, working notes, and letters, all of which are notoriously difficult to interpret, especially in the round. Bonhoeffer rides roughshod over this difficulty and complexity, and thereby trivialises the legacy of a modern-day, martyred Christian saint. It also tells in part an untrue story—the story of a man destined, indeed determined, to disavow a life of prayer, teaching, and diplomacy to become a would-be assassin and engage in violent political espionage and activism at any cost.

This is a (very) far cry from the man who, in 1930, urges American Christians to remember that they have brothers and sisters “in every people,” not just in their own, and that if the people of God were united then “no nationalism, no hate of races or classes can execute its designs and ... the world will have its peace.”

It’s a far cry from the man who, in November 1940, writes that “radicalism,” and “Christian radicalism” in particular, “arises from a conscious or unconscious hatred ... toward the world, whether it is the hate of the godless or of the pious.”

And it’s a far cry from the man who, at Christmas 1942, reflects on the “incomparable value” of having learned “to see the great events of world history from below, from the perspective of the outcasts, the suspects, the maltreated, the powerless, the oppressed and reviled, in short from the perspective of the suffering.”

Bonhoeffer therefore risks exposing Bonhoeffer’s legacy, as a theologian, pastor, and man of resistance, to yet further abuse. At a time when political and religious discourse is increasingly laced with xenophobic, authoritarian, and nationalistic rhetoric, and at worst Christian nationalistic rhetoric, this is not what is needed. It is not surprising that Bonhoeffer scholars across the world and Bonhoeffer’s own descendants have registered concern.

But is Bonhoeffer nevertheless worth the price of a ticket?

Perhaps surprisingly, I think that it is: if only for its denouement.

In a panoply of embellished facts, the film’s final scenes are in equal measure harrowing, arresting, and deeply moving. Shortly before his execution, Bonhoeffer leads his fellow prisoners in morning prayer, breaking bread and drinking wine with them in commemoration of the death of Jesus Christ. Bonhoeffer then walks to the gallows in peace, knowing that for him, as a disciple of Jesus Christ, his death is but the beginning of life.

It is such steadfast hope, in the face of all the humiliating absurdity of human contradictions (to borrow some words from Fyodor Dostoevsky), that the church and our world today is perhaps most desperately in need of.

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