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Assisted dying

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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.

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Community

Politics

8 November 2024

10 min read

How to respond when politicians talk about “our way of life”

Alasdair MacIntyre’s thinking helps us understand what we share across society.

Joel Pierce

Joel Pierce is the administrator of Christ's College, University of Aberdeen. He has recently published his first book.

Four men in suits, sit next to each other smiling, in the House of Commons.

Reform MPs in the House of Commons.

House of Commons, CC BY 3.0, via Wikimedia.

What is “our way of life”? It’s a phrase which slides easily into the rhetoric of politicians of every stripe. It’s what the Reform Party says is threatened by multiculturalism, but what do they mean by it? What kind of politics is sustained by talk of “our way of life” and is there a better way of thinking about such politics?

This summer, we made an exception to the time limit rule for television in my house, mainly so that I could have the Olympics on from morning to night. It’s a habit I acquired growing up in the United States, where an obsession over the quadrennial medal count is one of the few remaining things which bridges political and regional divides. During the Cold War, the Olympics were a way for Americans to proudly affirm the superiority of our way of life over the rigid training schedules and alien ways of the rival Soviet Union.

Although my memories begin around the fall of the Berlin Wall, old habits die hard, and so the Olympics, to me, was endless coverage of plucky underdog Americans overcoming the odds to defeat the machine-like discipline of a new set of rivals–now Russia and China

I moved to Britain just before the 2010 Vancouver Winter Olympics at which Britain won exactly one medal. At first I was bemused by the BBC’s coverage, which, of necessity, had to focus on British Olympians with little chance of winning. I was invited to cheer on eighth or ninth place finishers who had committed their life to a craft which would never bring the rewards of lasting fame or financial security. For them the reward was the Olympics themselves, the chance to compete amongst peers, to push themselves to their highest level, enjoying their sport and their performance for what it was, not for any external reward. In the terms of philosopher Alasdair MacIntyre, what these Olympians displayed was dedication to the internal goods of their sport–those goods that make a particular activity worth doing for its own sake. The Olympics were not about medals for them, but about showing what could be achieved if, as Olympians must do, they made their sport their way of life, dedicating themselves to its unique forms of excellence.

Sports, for MacIntyre, are but one example of a broader category he labels ‘practices’. Although MacIntyre has a technical definition of what counts as a ‘practice’, the general idea can be conveyed through examples he gives such as farming, researching history, architecture, chess, and chemistry. Practices are human activities which are worth doing for their own sake, which require a degree of skill and excellence, and in which what counts as that skill and excellence is, in part, defined and discerned by the people who participate in the practice. This last criterion points at something important about practices for MacIntyre: they are inherently social.

This is obvious in the case of sport. For an individual athlete to compete in a race they need not just other competitors to race against, but also trainers and coaches to prepare them for it, governing bodies to organise it, and, hopefully, spectators to cheer them on. It is, perhaps, less obvious in the case of individual farmer, but even here, one has to be taught to farm and, if one is wise, continues to learn and adapt through consulting with other farmers. A different way of putting this is that practices are the kinds of things which it’s not absurd to call “a way of life”. For an Olympic curler, curling is a way of life, just as much as farming is for a farmer.

There are many ways of life, many modes of being British, as diverse as the professions, hobbies, and passions which we find to have inherent worth.

However, this seems to offer little help in defining “our way of life” if it is being used in the way our politicians like to talk about it. If there’s one thing that I learned from all those BBC features of British Olympians way back in 2010, it was that aside from geographic proximity, there was not much that their way of life had in common with mine. I may be within driving distance of the rink where Winter Olympian Eve Muirhead learned to curl, but my workdays of wrestling spreadsheets and answering emails have little in common with ones spent lifting weights, studying strategy with coaches, and perfecting the just right spin on a stone as it’s released.

And, of course that’s not just true of Olympic athletes. The investment banker who attends our church shares a way of life with his colleagues in Edinburgh, London, and Tokyo, that is completely opaque to my wife and I, immersed as we are in the worlds of ministry and academia. I glimpse some of the internal goods of the practices of our dentist watching her check my daughters’ teeth and our plumber as he fixes our leaking radiators, but their way of life, the rhythms of their days, and what gives them satisfaction in their work as they move from appointment to appointment, eludes my understanding.

Where does this leave the search for a British way of life? If practices are as important to forming us as MacIntyre thinks, then the quest for any singular British way of life will ultimately be fruitless. There are many ways of life, many modes of being British, as diverse as the professions, hobbies, and passions which we find to have inherent worth. And even this characterisation does not go quite far enough, because all of these practices have a way of bursting the boundaries of Britishness if they really are worthwhile. A century and a half ago, football, rugby, and cricket were quintessentially British sports. Now they belong to the world.

Similarly, valuing these practices well within Britain has a tendency to open us to accepting those from outside our borders who can help develop them. The best footballer in Britain is Norwegian. Many of the doctors who ensured my daughters arrived safely after complicated pregnancies were originally from India and Pakistan.

Still, one might wonder if thinking about community through the lens of practices, as MacIntyre does, is too much of a solvent. Isn’t it a way of imagining us living near each other, but not with each other; siloed in our practices, in each of our communities, not understanding what our neighbours are up to? Not necessarily. For MacIntyre, the familiarity that arise from living near someone, hearing their worries at planning permission hearings, arguing with them at the local school’s parent council meetings, organising a community fundraiser together, or, even, being part of a family with them, can help develop an understanding of the internal goods of practices which we do not take part in. I haven’t lifted a brush to paper to since my secondary school art class, but my mother-in-law’s virtuosity with acrylics has led me to acquire an increasing appreciation for painting. Part of what helps facilitate this recognition is that, as MacIntyre argues, although the internal goods and the skills required to achieve them tend to be different for each practice, the virtues which we develop while pursuing them–patience, honesty, courage, self-control–are universal. Part of what helps us recognise others’ activities as practices, as worth doing for their own sake, are the virtues we see them develop as they do them.

This sort of recognition requires familiarity, the sort I might have with my neighbours in our corner of rural Aberdeenshire, but that I am unlikely to have with fellow citizens in Cornwall, Cardiff, London, or Glasgow. How then are we to respond to national politicians talking about “our way of life”? One answer might be: with extreme scepticism. This is MacIntyre’s approach. He rejects the nation-state, which he calls “a dangerous and unmanageable institution”, as a potential channel of communal unity. Instead, he calls on us to admit that modern nation-states exist as a contradiction, being both “a bureaucratic supplier of goods and services” and yet also something treated as sacred, which we are asked, on occasion, to surrender our lives to preserve. He notes with characteristic acerbity, “it is like being asked to die for the telephone company.”

However, here I’d temper MacIntyre’s rhetoric somewhat. While my attachment to bankers in Canary Wharf is largely a happenstance of history, a contingent fact generated by long forgotten necessities of eighteenth century geopolitics, it has nevertheless resulted in both of us being issued the same passport, governed by the same tax regime, and having the same set of regulatory agencies to complain to when things go wrong. Those may be manifestations of what MacIntyre disparages as “a bureaucratic supplier of goods and services”, but they nevertheless do bind us together. As such we both have an interest in making sure this bureaucracy acts as justly as it can, not because it is the embodiment of all that is British, Britain is much too diverse and interesting to be fully embodied in our political institutions, but because we all have an interest in the institutions in which we are enmeshed, British or otherwise, being run as justly as possible.

Surely politics is all about securing as much money and resources as possible for the people most like oneself. That, it seems, is often the unstated assumption when the talk of “our way of life”

Because we find ourselves tied together by these institutions to a diverse collection of people, we have an interest in learning about those with whom we live. Even those who are far away. And to also celebrate when goods and services delivered by our institutions result in success to which we, in a remote way, have contributed. I may not share a way of life with Adam Peaty, but, thanks to the BBC, I can have a glimpse into what his way of life is and can be happy that through my taxes I have contributed, in a small way, to helping him win another medal. Since that 2010 Winter Olympics Britain has come quite a long way and there is nothing wrong with a little vicarious pride in our athlete’s accomplishments.

But I can also be proud of athletes who didn’t win. Ones like BMX rider Beth Shriever who handled her unexpected last place finish in her final with a kind of grace and maturity, the kind of virtue, which someone more dedicated to her practice than to just winning can demonstrate. It is the facilitating of this kind of moral achievement which is more valuable than any medal.

Similarly, I can rejoice when a new hospital gets built in a neglected area in London, or more council housing is supplied to people in need in Edinburgh, hopeful that these lead to my fellow citizens achieving the kind of flourishing lives they deserve. I can be angry, when I discover that the money I’ve paid towards postage has been used to prosecute innocent victims of a computer glitch, and pleased when the opening of a new rail line eases the otherwise stressful commute of tens of thousands in London. The state may be a bit like a telephone company, but a well-run utility can do a lot to supply people with the goods they need to make their lives. As long as I’m a subscriber, as long as I’m tied to people through national institutions like the state, I have a moral duty to ensure that they’re run as well as possible.

This way of thinking about politics may strike some as idealistic, the kind of view only a naive Christian ethicist could endorse. Surely politics is all about securing as much money and resources as possible for the people most like oneself. That, it seems, is often the unstated assumption when the talk of “our way of life” is deployed and why so much coalition building in our politics turns on finding a convenient other against which to define “our” similarity. Take your pick: immigrants, the EU, woke elites, the Tories, or Westminster (among a certain brand of politician here in Scotland).--. Growing up in the USA, the Soviets, and then the Chinese, and now, depending whether one lives in a Republican or Democratic district, the other political party, have served the same purpose. The problem is that we aren’t that similar, we are and always have been a diverse lot with diverse needs. Every nation is. There is no one British way of life and to allow our politicians to try to sustain the fiction that there is lets them off the hook. Solving deep seated economic and social inequality is hard. Blaming immigrants for not embracing our way of life is easy.

So, perhaps the sort of politics that I am talking about here is idealistic, nevertheless it is the only kind that can sustain a just government in the long term. Without acknowledging the importance of goods we only partly understand which are pursued by people whose ways of life are different from our own, we cannot hope to sustain the minor miracle of coordination and mutual aid that history has gifted us with in our united kingdom.