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

Death & life

Digital

Film & TV

28 March 2025

6 min read

Mickey 17: If we replicate then where does our humanity lie?

Bong Joon-ho has a stark warning about dehumanization.

Krish Kandiah

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

Warner Bros.

One of my favourite films of the last decade was Bong Joon-ho’s Parasite, a groundbreaking masterpiece in social commentary, humour and suspense. It won four Academy Awards in 2020, including Best Film - which was a first for a non-English language film - as well as numerous other accolades. So, when the director’s latest project, Mickey 17, was announced, I was eager to see if Bong could deliver another cinematic triumph of similar beauty, depth and precision.

Mickey 17 took me by surprise. To be honest, the change in genre took some adjusting to, but as I recalibrated my expectations, I realised that the film nevertheless retained Bong’s trademark thought-provoking and daring exploration of identity, purpose and the human condition.

Mickey 17 is in fact the eighth major film from Bong Joon Ho, but he is probably best known for Snowpiercer and Parasite. These films share common themes, particularly the stark divide between rich and poor and the rigid, two-tier nature of human society. In Parasite, we see the poor trapped in the flood plains of Seoul while the elite live in grand houses on hills. The film is structured around the visual metaphor of descent and ascent. In Snowpiercer, the class struggle is represented by the different carriages of the train, with the poor at the back of the train suffering in squalor while the privileged at the front enjoy luxury.

Us and them

In Mickey 17, this theme of societal hierarchy continues but in a futuristic, intergalactic setting. The divide now exists between the expendables—a class of human clones used for dangerous tasks—and the higher echelons of the spaceship crew, who are embarking on a mission to colonize a new planet.

Mickey’s journey to the spaceship begins in poverty. He and a supposed friend start a business, funding it through a loan shark. When the business fails, the loan shark threatens their lives. Desperate, Mickey signs up for the space expedition, barely reading the fine print—only to discover that he has agreed to be an expendable.

All expendables are humans who have been digitized – their entire bodies, brains, and psychologies are stored as data. When they die, they are simply reprinted, with only a week’s worth of memory lost. They exist to perform dangerous tasks such as testing the effects of radiation exposure, new vaccines, or extreme planetary conditions. In Mickey’s case, he has been fatally experimented on 16 times. He has been resurrected to his seventeenth version, and while he is still called Mickey, the question is whether this Mickey is the same Mickey who signed up for the space mission in the first place.

What does it mean to be human?

One of the film’s central philosophical questions is: What makes someone human? Mickey is biologically and mentally identical to himself, yet each iteration has a different personality. Some versions of him are more caring, others more aggressive or anxious. If he is just a replica, then where does his humanity lie? Is he just a product of his genetic code, or is there something more—something intangible—that makes him who he is?

It is the same question that has been asked since the beginning of time. The Bible claims that the first human beings were created in the image of God, but what does that mean? Did that first iteration of humankind have the same power, the same worth, the same purpose as God? This was the forbidden fruit dilemma – Adam and Eve were already like God, but the serpent tempts them to eat the fruit so they could be like God in a different way.

In our technologically advanced world, we are faced with the same fundamental difficulty in defining personhood: are we physical and spiritual beings with intrinsic dignity, infinite worth and unique purpose, or are we just biological replications existing for pre-programmed functions. If human cloning were to become common practice, would each clone be truly human?

What is a human life worth?

As far as the ship’s crew is concerned, Mickey is expendable. His pain, suffering, and even his existence are secondary to the mission. While the crew pursue the possibility of extending their own influence and power by colonising another planet, the expendables have no influence or power at all. The portrayal of this devaluing of human life is the most challenging of themes in Bong’s most popular films. In Parasite, the poor are only useful to the rich until they become an inconvenience. In Snowpiercer, the people at the back of the train serve those at the front, but they are seen as disposable. In Mickey 17, this exploitation is taken to its extreme—Mickey’s entire purpose is to die over and over again for the good of others.

In a world that often assigns value based on productivity, Mickey 17 provides a stark warning about dehumanization. If we begin to measure worth based on what someone can do rather than who they are, we risk treating people as commodities. The Adam and Eve story turns that on its head. They were declared ‘good’ before they were given their roles to take care of one another and creation. Their function was an overflow of their dignity, not the other way around. And even after the forbidden fruit incident where the world was infected with sin and death there is a thread that reminds us that each life is precious. The Psalms declares that each of us is “fearfully and wonderfully made”. Jesus spent his life upholding the dignity of those society deemed inconvenient and expendable – the poor, sick and marginalised.

What does death achieve?

Despite dying multiple times, Mickey still fears death. Even though he knows he will be reprinted, the experience remains terrifying. No amount of technology, it seems, can remove the instinctive human fear of mortality. In fact the question that everybody that has contact with Mickey wants to ask is what death feels like, because everyone, whether a friend or simply a user of Mickey has to confront their own mortality.
In the final act, Mickey makes a choice. Instead of living in an endless cycle of death and resurrection, he chooses to grow old with one person. He destroys the only means by which he could achieve immortality. The film is suggesting that relationship is more important that reusability. Finiteness—the ability to die permanently—is part of what makes life meaningful.

The Bible teaches that there is an Adam 2.0. While the first Adam brought sin and death into the world, the second Adam – Jesus – brought redemption and eternal life. Both Jesus and Mickey choose death to break the cycle of suffering. But while Mickey chooses to abandon his contract as an expendable, Jesus willingly became expendable for the sake of others. His death was a once-for-all sacrifice that broke the power of death for all.

What about resurrection?

If there is life beyond this life what does it look like? Is it merely reprinting? A chance to try again? Or is there, as Adam 2.0 leads us to believe, a resurrection into a whole new world that even science fiction cannot begin to imagine?

At its heart, Mickey 17 asks profound existential and ethical questions. It forces us to confront what it means to be human, what that human life is worth and how we deal with our mortality. It doesn’t provide us with answers but it invites us to wrestle with these crucial ideas. And in doing so, it points us back to the only hope that is worth having: a view of life where value is not earned, our existence is not expendable, and death is not the end.

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