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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Wildness

7 November 2024

7 min read

It’s getting harder to be wild in this world

We’ve trapped and tamed wilderness into a commodity.

Elizabeth Wainwright

Elizabeth Wainwright is a writer, coach and walking guide. She's a former district councillor and has a background in international development.

Against a night sky a lit up face is blurred by the camera movement.

Under a Dartmoor night sky.

Yousef Salhamoud on Unsplash.

Some while back, my husband rearranged the books in our house, making sure that they were grouped together by theme. We have a lot of books, and there are now themes and sub-themes. It was quite an operation. Within the nature-related books, he created a separate shelf for books that have ‘wild’ in the title. We joked about it, but it made me think about how I’d noticed ideas of ‘wild’ pop up in lots of places in recent years: on clothing and stationery (with leaves or words like ‘keep growing’ printed), in shop windows (furniture displays draped in plastic greenery and fake animal skins), on social media (there are accounts that have ‘wild’ in the title connected to farming, conservation, publishing, personal development, coaching, poetry, business, and more), and in book shops (of which we apparently have only half the stock).

A quick online search on the topic of wilderness quickly leads me to conservation initiatives and statistics on the state of nature, but it also leads me to nature connection experiences, wild swimming, wild camping, soul work, and more. Wilderness becomes a pliable and hard-to-define term. It can relate to the natural world, to wildlife and natural spaces that have avoided human domination. It can also relate to the inner world, to spiritual experiences or to isolating and challenging times. But however you approach it, wilderness – inner, outer – seems to be having a hard time.

In recent months, wild camping has come under the spotlight. Dartmoor is the only place in England where wild camping is legal, and this this access helped to form me: as a teenager I hiked and camped with friends, encountered Dartmoor ponies trying to steal our food in the night, stomped through bogs and wolfed down boil-in-the-bag meals as the sun set. As an adult I’ve camped alone in a bivvy bag, my soul singing back to the Milky Way shining above me. Now, these experiences feel as much in need of protection as the nature they depend on, since a wealthy landowner decided to try and prevent people from undertaking this ancient practice of sleeping under the stars. The court case is ongoing, but it has highlighted the fragility of our access to nature here in England. Just 8 per cent of English countryside is accessible, and 3 per cent of rivers have an uncontested right to swim. Now, the last remaining right to sleep under the stars is under threat.

It is hard to know what we’re losing when it becomes harder and harder to see and touch the real thing.

We live in a time of crisis not just of the state of nature, but also of how we experience the natural world. In a recent study of nature connectedness, Britain was ranked lowest of all the countries surveyed. Our biodiversity is in crisis and so is our ability to encounter the natural world. This feels heightened by a way of being in the western world that sees us all living in our individual houses, working hard to pay for them, shuttling children and selves through schedules, spending fewer and fewer hours outside and with each other.

And this is not just a problem ‘out there’, because inner and outer landscapes are linked. It is unsurprising to me that in the UK at least, levels of good mental health, biodiversity, and access to nature have all been in decline. Disintegration of one is, I think, deeply connected to disintegration of the other.

These linked crises feel further threatened by the trapping and taming of ideas of wilderness, wrapping it into trends and materialism, commodifying it. There are some brilliant and essential initiatives helping to re-wild our inner and outer worlds. But there are also offerings that use wilderness imagery and the freedom and adventure associated with it to sell products and services, or as backdrop to human endeavour, or as a destination or resource for our consumption. I think a commodified wild can get in the way of the actual wilderness we need both externally and internally. This commodification is, I think, affecting our understanding of what the wild is and why it matters. It is hard to know what we’re losing when it becomes harder and harder to see and touch the real thing.

If real wilderness is everywhere but where we need it right now, how might we re-find it – in the natural world, but also within ourselves and our communities? Answering that question is work that many people are focused on now in all kinds of ways, and a short essay cannot begin to offer a full response. I will write more on this topic. But the question I have in mind at the moment is, how do we invoke wildness and wonder in the landscape of the modern world? – a physical landscape that is being stripped of nature, but also a social landscape that can often diminish our humanity. Perhaps a simpler way to ask the same question is, how do we not just survive life but get excited about it? – How do we love ourselves, our neighbours, and creation enough to deeply and truly care for these things?

Time stops, something says: here, look at this, it is everything.

There are of course structures, systems, and powers that need to change so that people can move out of mere survival, and so that the wild world is restored. I am not exploring those things here. Here, I want to simply share three things that lately, have energised my ability to feel the love, the excitement, and the desire to cherish and protect our hearts, our relationships, and the generous world that hosts us all. Perhaps by reawakening these things, we might find motivation and sustenance for tackling structures and systems.

First, I have been noticing what my young daughter notices. The light shining off a puddle; the way an ant crawls on her hand; the bright silver moon in the sky. I have never struggled to access the exhilaration of the natural world, but seeing through her eyes, I am doing so again. Time stops, something says: here, look at this, it is everything. The medieval mystic Julian of Norwich saw the wonder of the world, and God’s love for it, in a single hazelnut. She recounts her visions in her book Revelations of Divine Love. Sometimes connecting with the specific can help us see and face the global.

Second, there are authors who help me summon wildness and wonder in the landscape of the modern world, and in a future Seen & Unseen piece I’ll take us on a tour of some of those I love the most. Some of the authors are ancient. In Psalm 78, I read “…they forgot what he had done, the wonders he had shown them”, and “…they kept on sinning; in spite of his wonders, they did not believe.” If sin is a kind of disconnection, perhaps our disconnection from creation might lead our gaze to turn inward, and to land on things that do not call forth the best of humanity, rather than the wonder of each other and the world around us. That we are able to forget wonder is something we must remember and work to counter.

Third, I have been thinking through the encounters that have most exposed me to wilderness of the world and of my soul and of relationship – both the uplifting and the challenging. Encountering the vastness of that shining and vertigo-inducing Dartmoor night sky; encountering others in relationships that have helped me slip my skin and enter their unknowability and fragility and beauty; encountering contexts that seem too broken for repair and yet still light enters in. It is in these encounters that I first found God dwelling, and when I followed his trail, I noticed that throughout the Bible there are many people who experience the challenges, joy, and lessons of the wilderness. Wilderness is not just beauty – it can also be unknowable, disorienting, scary. For 40 days in the wilderness, but also in the beauty of the lily of the field and birds of the air, Jesus is right there with us, showing that God can meet us in beauty and barrenness, in wonder and in despair. Again and again in the Bible I see how God loves the world, how he calls it constantly to life through resurrection, through re-creation, through that three-in-oneness of father/son/holy spirit, of self/other/world, of body/encounter/mystery.

Now, I think our souls and societies might benefit from investing in relationships first conjured in Eden: with a garden, with a human, with God and the mystery he points us to. These things feed each other; when one suffers so do the others. As we face a disintegrating and increasingly commodified natural world, a mental health crisis, and an epidemic of loneliness, I think we are being called back to that garden, and to the kinds of wildness it made possible. I’ll look forward to exploring these themes more.