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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.

How to navigate a culture war

Blaise Pascal shows us what really underlies our contemporary battles.

Graham Tomlin

Graham is the Director of the Centre for Cultural Witness and a former Bishop of Kensington.

Maxime Gilbert on Unsplash.

We often say these days that we are more polarised as a society than ever before. But we're wrong. Maybe the USA is experiencing a particularly sharp divide right now, but they have had their own, much more violent troubles in the past. And in Europe, and especially in Britain, we know a fair bit about culture wars that were literally that – wars.

In the 17th century, we English had our own civil war where we literally killed each other over religion and politics. We even killed a king. The French did something similar and even more vicious just over 100 years later. That is real polarisation. However spiteful Twitter/X arguments may get, I don't think Charles III or even Kier Starmer is quaking in their beds expecting to be put on trial for treason.

So maybe our history has something to teach us about how we navigate culture wars.

The literary critic Terry Eagleton once wrote of our age:

“the world is accordingly divided between those who believe too much and those who believe too little. While some lack all conviction, others are full of passionate intensity.”

We tend to think our contemporary divide between left and right, progressives and conservatives is something new. But we can find echoes of this in previous times.

A case in point was the mid-17th century – the time of many other upheavals in Europe. Part of the febrile atmosphere of the time saw fierce arguments between rationalists and sceptics.

There were at the time, two broad strands of thinking about the human condition. On the one had there were the ‘Dogmatists’ who were sure that they knew everything through use of reason or the application of philosophical or scientific method (like René Descartes). On the other hand, there were the ‘Sceptics’ who thought everything was random, or custom, and there is no final Truth to be found (like a figure from the century before – Michel de Montaigne).

Of course, our own time has its fair share of people with an overwhelming confidence in the power of human knowledge, and the physical sciences in particular, to unlock the secrets of life, the universe and everything. The ‘new atheist’ project of Richard Dawkins and friends was hugely confident in reason and its capacity to tell us all we need to know, dispatching religion to the dustbin of history and instead placing an unshakable faith in the empirical methods of science. It had - and has - definite similarities with this picture of human knowledge.

Yet on the other hand we also have, in the progressive postmodern project, those who reject any kind of underlying rationality or sacred order either above us or beneath us. For them, there is no underlying Truth to be discovered, and they delight in revealing the instability and illusory nature of any claim to truth. It sounds very much like the culture wars of our time.

One enigmatic 17th century figure charted a way through this dilemma - Blaise Pascal. When he looked at his century’s culture war, he thought both sides had a point. There is, he observed…

…open war between men in which everyone is obliged to take sides, either with the dogmatists or with the sceptics, because anyone who imagines he can stay neutral is a sceptic par excellence…. Who will unravel such a tangle? This is certainly beyond dogmatism and scepticism, beyond all human philosophy. Humanity transcends humanity. Let us then concede to the sceptics what they have so often proclaimed that truth lies beyond our scope and is an unattainable quarry, that it is no earthly denizen, but at home in heaven lying in the lap of God, to be known only insofar as it pleases him to reveal it.

So far, he says, the sceptics, like Montaigne, are right. Truth is beyond our grasp, it does not reside here on earth, openly obvious and ready to be found. If it exists, it exists in some world above us, beyond our reach. How do we even know if we are asleep or awake, given that when we dream, we are as convinced that we are awake as we are when we are truly awake?

And so, modern progressives, looking to dismantle the assumed results of previous understanding, due to its inherent colonial, patriarchal or abusive past, delight in showing how random and arbitrary is so much of what we take for granted from the past. And, Pascal would add, they have a point. Many of our legal, political and cultural assumptions are purely cultural and arbitrary, and sometimes simply serve to the advantage of the rich and powerful rather than the poor and marginalised.

Yet on the other side, the ‘dogmatists’, like Descartes, have their strong point, which is that we cannot doubt natural principles. The acids of deconstruction can only take you so far. The most sceptical philosopher still puts the kettle on assuming that it will boil to make a cup of tea. She gets up in the morning assuming that the sun will rise and set again at the end of the day. Despite the corrosive effects of scepticism, Pascal wrote,

“I maintain that a perfectly genuine sceptic has never existed. Nature backs up helpless reason and stops it going so wildly astray.”

Despite all our doubt, we still live in a world with order and predictability. Scepticism keeps bumping up against reality.

So, modern conservatives point to a deeper ‘givenness’ to things, an order within the natural world that we did not create, and yet, mysteriously, seems to be prearranged before we got here. Scientific exploration does make sense. There is a regularity to nature that we can, indeed have to, depend on. Sexual differences exist and can’t be ignored. We are not entirely free to override the natural order of things - there is a deeper rhythm to nature and its capacity for renewal that we only mess with at our peril, as climate change has taught us. As a result, the age-old battle between rationalists and sceptics, progressives and conservatives, will never find resolution, as the arguments flow back and forth.

Christian faith includes both progressive and conservative impulses. It can make sense of both of them. Christians are aware of the brokenness of the world and therefore long to see it changed. The progressive impatience with the way things are, and the yearning for a better world has its roots in Christian faith.

Yet at the same time, Christianity discerns a divinely created order to the world, a rhythm to the natural world, that cannot be broken and needs to be respected. Therefore, an inherent conservatism is part of Christian faith as well. In other words, the Christian story can explain both and offer a bigger picture than either.

For Pascal, Christianity offers a diagnosis for this mystery of the human condition, the complex mix of grandeur and misery, infinity and nothing, sceptic and rationalist, in the simple, yet endlessly generative idea that we humans are gloriously created, deeply fallen and yet offered redemption through Jesus Christ. Our sadness is heroic and tragic. In Pascal’s suggestive image, it is “the wretchedness of a great Lord, the wretchedness of a dispossessed king.”

“We show our greatness,” says Pascal, “not by being at one extreme, but by touching both at once and occupying all the space in between.” For him, the very existence of such culture wars points to the truth of the Christian diagnosis of the human condition.

Pascal offers us a way between the Scylla of Progressivism and the Charybdis of Conservatism – or perhaps better, to embrace the best of both. Culture wars are tricky to navigate. Yet they might find resolution if we allow them to point us to a deeper reality - our strange mixture of greatness and sadness. And not losing sight of either side of this enduring truth.

Graham Tomlin is the author of Blaise Pascal: The Man Who Made the Modern World (Hodder) £25.

Watch Graham explain why he is fascinated by Pascal.

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