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.

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Creed

Death & life

Digital

17 March 2025

6 min read

AI deadbots are no way to cope with grief

The data we leave in the cloud will haunt and deceive those we leave behind.

Graham Tomlin

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

A tarnished humaniod robot rests its head to the side, its LED eyes look to the camera.

Nicholas Fuentes on Unsplash.

What happens to all your data when you die? Over the years, like most people, I've produced a huge number of documents, letters, photos, social media posts, recordings of my voice, all of which exist somewhere out there in the cloud (the digital, not the heavenly one). When I die, what will happen to it all? I can't imagine anyone taking the time to climb into my Dropbox folder or Instagram account and delete it all? Does all this stuff remain out there cluttering up cyberspace like defunct satellites orbiting the earth?

The other day I came across one way it might have a future - the idea of ‘deadbots’. Apparently, AI has now developed to such an extent that it can simulate the personality, speech patterns and thoughts of a deceased person. In centuries past, most people did not leave behind much record of their existence. Maybe a small number of possessions, memories in the minds of those who knew them, perhaps a few letters. Now we leave behind a whole swathe of data about us. AI is now capable of taking all this data and creating a kind of animated avatar, representing the deceased person, known as a ‘deadbot’ or even more weirdly, a ‘griefbot’.

You can feel the attraction. An organisation called ‘Project December’ promises to ‘simulate the dead’, offering a ghostly video centred around the words ‘it’s been so long: I miss you.’ For someone stricken with grief, wondering whether there's any future in life now that their loved one has gone, feeling the aching space in the double bed, breakfast alone, the silence where conversation once filled the air, the temptation to be able to continue to interact and talk with a version of the deceased might be irresistible.

There is already a developing ripple of concern about this ‘digital afterlife industry’. A recent article in Aeon explored the ethical dilemmas. Researchers in Cambridge University have already called for the need for safety protocols against the social and psychological damage that such technology might cause. They focus on the potential for unscrupulous marketers to spam surviving family or friends with the message that they really need XXX because ‘it's what Jim would have wanted’. You can imagine the bereaved ending up being effectively haunted by the ‘deadbot’, and unable to deal with grief healthily. It can be hard to resist for those whose grief is all-consuming and persistent.

Yet it's not just the financial dangers, the possibility of abuse that troubles me. It's the deception involved which seems to me to operate in at a number of ways. And it's theology that helps identify the problems.

The offer of a disembodied, AI-generated replication of the person is a thin paltry offering, as dissatisfying as a Zoom call in place of a person-to-person encounter.

An AI-generated representation of a deceased partner might provide an opportunity for conversation, but it can never replicate the person. One of the great heresies of our age (one we got from René Descartes back in the seventeenth century) is the utter dualism between body and soul. It is the idea that we have some kind of inner self, a disembodied soul or mind which exists quite separately from the body. We sometimes talk about bodies as things that we have rather than things that we are. The anthropology taught within the pages of the Bible, however, suggests we are not disembodied souls but embodied persons, so much so that after death, we don't dissipate like ethereal ‘software’ liberated from the ‘hardware’ of the body, but we are to be clothed with new resurrection bodies continuous with, but different from the ones that we possess right now.

We learned about the importance of our bodies during the COVID pandemic. When we were reduced to communicating via endless Zoom calls, we realised that while they were better than nothing, they could not replicate the reality of face-to-face bodily communication. A Zoom call couldn't pick up the subtle messages of body language. We missed the importance of touch and even the occasional embrace. Our bodies are part of who we are. We are not souls that happen to temporarily inhabit a body, inner selves that are the really important bit of us, with the body an ancillary, malleable thing that we don't ultimately need. The offer of a disembodied, AI-generated replication of the person is a thin paltry offering, as dissatisfying as a virtual meeting in place of a person-to-person encounter.

Another problem I have with deadbots, is that they fix a person in time, like a fossilised version of the person who once lived. AI can only work with what that person has left behind - the recordings, the documents, the data which they produced while they were alive. And yet a crucial part of being human is the capacity to develop and change. As life continues, we grow, we shift, our priorities change. Hopefully we learn greater wisdom. That is part of the point of conversation, that we learn things, it changes us in interaction with others. There is the possibility of spiritual development of maturity, of redemption. A deadbot cannot do that. It cannot be redeemed, it cannot be transformed, because it is, to quote U2, stuck in a moment, and you can’t get out of it.

This is all of a piece with a general trajectory in our culture which is to deny the reality of death. For Christians, death is an intruder. Death - or at least the form in which we know it, that of loss, dereliction, sadness - was not part of the original plan. It doesn't belong here, and we long for the day when one day it will be banished for good. You don’t have to be a Christian to feel the pain of grief, but paradoxically it's only when you have a firm sense of hope that death is a defeated enemy, that you can take it seriously as a real enemy. Without that hope, all you can do is minimise it, pretend it doesn't really matter, hold funerals that try to be relentlessly cheerful, denying the inevitable sense of tragedy and loss that they were always meant to express.

Deadbots are a feeble attempt to try to ignore the deep gulf that lies between us and the dead. In one of his parables, Jesus once depicted a conversation between the living and the dead:

“between you and us a great chasm has been fixed, so that those who might want to pass from here to you cannot do so, and no one can cross from there to us.”

Deadbots, like ‘direct cremations’, where the body is disposed without any funeral, denying the bereaved the chance to grieve, like the language around assisted dying that death is ‘nothing at all’ and therefore can be deliberately hastened, are an attempt to bridge that great chasm, which, this side of the resurrection, we cannot do.

Deadbots in one sense are a testimony to our remarkable powers of invention. Yet they cannot ultimately get around our embodied nature, offer the possibility of redemption, or deal with the grim reality of death. They offer a pale imitation of the source of true hope - the resurrection of the body, the prospect of meeting our loved ones again, yet transformed and fulfilled in the presence of God, even if it means painful yet hopeful patience and waiting until that day.

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