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

Books

Culture

Leading

Politics

20 November 2024

5 min read

Blair’s revelatory sermon to Starmer

What can the former Prime Minister teach about leadership?

Krish Kandiah

Krish is a social entrepreneur partnering across civil society, faith communities, government and philanthropy. He founded The Sanctuary Foundation.

Tony Blair at rest.

The 1990s are enjoying a revival—from the return of baggy jeans and bucket hats to the reunion of Oasis, and, perhaps most significantly, a Labour government in power once again. Unlike the fervent optimism of 1997, when Tony Blair swept to victory with D: ream’s hit song Things Can Only Get Better as an anthem, today’s Labour government faces criticism for a perceived lack of vision. Luckily, Tony Blair has just released his new book: On Leadership—perhaps a timely read for the current Prime Minister.

Blair's leadership credentials are, at one level at least, pretty impressive: he won three consecutive elections and was the first Labour Prime Minister to do so. His achievements include playing a crucial role in the Northern Ireland Peace Process, reducing NHS wait times, and making a substantial investment in public services. Blair also took a courageous stance with U.S. President Bill Clinton by intervening in the Kosovo conflict against the advice of the UN. He remains however indelibly associated with the controversial 2003 invasion of Iraq that resulted in the deaths of 179 British personnel, and hundreds of thousands of Iraqi civilians.

In this climate of scepticism toward political leaders, Blair's reflections on leadership invite critical questions: Who is this book for? Where is the vision? And even, intriguingly, do we now 'do God'?

Who's it for?

Blair’s book is not a typical guide to general leadership principles; rather, it’s an insider’s view on leading a country. For the average reader, it’s like overhearing a high-level seminar on statecraft—a glimpse into the “room where it happens.”

Maybe there’s a bit of an audience reality check going on in the same way that a TV documentary on what-it’s-really-like-to-be-the-England-football-manager might deliver. Many football fans are happy to shout at our televisions when most have not got even the remotest clue of the challenges and pressures national coaches are under. So perhaps if Blair can tell us how hard it is to handle the myriads of competing challenges as the leader of a nation, readers might better understand the weight of leadership and approach politics – and politicians -with greater humility.

One of the most helpful reflections the book offers was Blair’s self-analysis on three stages of leadership. The first is the new leader listening eagerly; the second comes when they think they know everything, and finally, there’s a third stage of maturity when “once again, with more humility, they listen and learn”. He argues that his book’s purpose is to shorten the learning curve and get leaders to the third stage more quickly.
This a noble cause, but there are times when this book feels like a sermon preached by a slightly unscrupulous vicar, in a church where everyone knows there’s only one person the preacher has in mind. This can make everyone else feel they are there just to fill up the pews so that the message gets delivered. For Blair, his message and his book seem to be very much for Sir Keir Starmer; a plea to him to listen and learn from others.

Where’s the vision?

Blair encourages leaders to make a meaningful impact with their time in office. Recalling a conversation with Shimon Peres, he writes, “Do you want to be in the history books or the visitors’ book?” For Blair, leadership is about pushing boundaries, meeting resistance with persistence, and making difficult choices when others hesitate. He writes, “If you, as a leader, are not a changemaker in this world, it is you who will be changed.” His words on taking risks and demonstrating resilience are certainly inspiring. However, he often focuses on how to lead effectively, with limited exploration of what motivates us to seek positions of leadership in the first place — a disappointing missing focus on moral purpose.

This emphasis on strategy over ideology is evident in chapter titles: The Supreme Importance of Strategy versus The Plague of Ideology. Blair is critical of rigid ideologies, advocating instead for flexibility and pragmatism. He contrasts ideological rigidity with a more agile and pragmatic approach, which could sound like its own simply going-with-the-flow ideology, - a situational ethical approach. This feels very different to the Tony Blair that took on the United Nations over the Serbian genocide in Kosovo. He appeared to take a moral stance driven by a commitment to human rights rather than going with a more pragmatic laissez-faire solution. Blair’s emphasis on pragmatism, while useful, may leave readers wanting more on the values that shape a visionary leader.

Blair includes a joke, a very good one, that feels accidentally pertinent: some people die and the Devil appears and asks them, before they settle for Heaven, to take a look at Hell, because it’s not as bad as they’ve heard. When they see the “drinking and debauchery” in Hell, they ask to be damned. But then they wake up in the real Hell – “cold, miserable and horrible” – and demand to know why it looks nothing like what the Devil showed them. “Ah well,” says the Devil, “back then I was campaigning.”

He meant it as a joke, but the lack of moral clarity in the book made me feel he was sharing more than he intended about the state of political leadership right now. Perhaps sharing to many more than just those he wrote this sermon for. It certainly encapsulates the growing chasm between political promises and reality, as well as illustrating the reason why many people feel disdain, distrust and disappointment in all politicians who say whatever they need to say to get elected.

Are we doing God now?

Famously, when asked about his faith while Prime Minister, Blair was interrupted by his press secretary, Alastair Campbell, who declared, “We don’t do God.” Yet in this book, Blair invokes Moses as an example of leadership under difficult circumstances: “Never underestimate the degree to which people crave leadership. Back to Moses again. The Israelites simultaneously hated and craved his leadership. If you remember, they reached the promised land (though, yes, I know, he didn't).”

Blair sees in Moses a leader who maintained strength and conviction, even in the face of public criticism—a relatable comparison for politicians navigating the pressures of modern social media. Whether or not Blair is “doing God” in this book, he draws inspiration from Moses as a model of resilience and substance, inviting readers to consider leadership as a balance between staying grounded in one’s values and withstanding external pressure.

In the end, On Leadership is a reflective, sometimes provocative take on leading a nation, full of insights that swing from the practical to the idealistic. But it also raises important questions about the ultimate purpose of leadership and the need for a clear moral compass. For a public that remains sceptical of political motives, Blair’s leadership lessons may provide timely, if imperfect, revelation.