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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9 April 2025

4 min read

Is it OK to pray for the death of a dictator?

What happens when the mighty lose their thrones.

Simon Burton-Jones

Simon is Bishop of Tonbridge in the Diocese of Rochester. He writes regularly round social, cultural and political issues.

Bullet holes on a wall and white paint outlines mark the site of an execution

The wall where Nicolae and Elena Ceausescu were executed.

NPR.

The end, when it comes, can be nasty, brutish and filmed.

Muammar Gaddafi, self-styled Brotherly Leader and Guide of the Revolution, spent the last moments of his life cowering in a Libyan sewer after an air strike on his convoy. On discovery, a mob subjected him to some ghastly final abuses before death – the kind of ending he had mercilessly condemned thousands to. It was almost biblical in its parabola, and it was recorded on a wobbly camera.

But it was not the first of its kind in this generation. On Christmas Day 1989, the disfigured face of Nicolae Ceausescu was broadcast on TV following his summary execution by hastily assembled opposition forces in Romania. Only days previously, he had been an unassailable dictator.

Vladimir Putin has spoken about Gaddafi’s ending, and it clearly troubles him, but perhaps Ceausescu’s death is lodged in the dark recesses of his mind because it was the one bloody end of all the communist leaders of eastern Europe.

Being a dictator is an all-consuming job. Too many domestic and foreign enemies are made along the way for the dictator to drop their vigilance. And their downfall often comes at the hands of those closest to them; by definition, these people know the dictator’s movements and weaknesses better than others and are best placed to exploit them. The military must be equipped to suppress dissent, but give it too much power and the generals pose a risk to the dictator. Yet if the military lacks the hardware, control of the population becomes harder. Many dictators surround themselves with specially trained loyal guards to defend against the military, but the rule of terror means no-one speaks the honest truth and so risks appear everywhere. No wonder dictators are usually paranoid and themselves racked with the fear that a culture of capricious violence induces in everyone.

These and other theories are explored by Marcel Dirsus in his compelling book How Tyrants Fall (John Murray, 2025). Dirsus notes how dictators require money, weapons and people to survive in office and for the elites around them to believe these goods will remain in place. They also need to immerse the surrounding elites in blood guilt, so that their fate becomes entwined with the dictator’s; Saddam Hussein compelled others to join him in the murder and execution of opponents.

For Dirsus, there are two ways to topple a tyrant. The most direct is to take them out, but this is rarely straightforward. Coup attempts are often shambolic in their planning and even well-orchestrated ones usually fail; the consequences for those implicated are always horrendous. The second route is patient and pragmatic, looking to weaken the tyrant, strengthen alternative elites and empower the masses. External powers often have minimal influence unless, like the US in Iraq, the country is invaded and the tyrant deposed. Sanctions often fail to hurt the elites; a state’s geographic proximity to the tyrant’s nation can be useful, as it gives a base from which opponents of the regime can work.

Modern technology is changing the face of political action, making it easier for large groups to mobilise against regimes, as seen in the short-lived Arab Spring. It also enables dictators to track opponents more successfully than even the feared Stasi in East Germany. Right now, it feels like the tyrants are ahead in this game.

Shortly after the full-scale Russian invasion of Ukraine in February 2022, a friend said to me that he was praying for Putin’s death or downfall. I asked him how sure he was that the person who replaced Putin would be better. If the pragmatic route for toppling a dictator involves strengthening different elites and empowering the masses, the likelihood is that the elites will take over, not the masses. Dictators never allow the components of civil society to form; democratic institutions take decades to build. And they rarely anoint successors in advance, for fear alternative power bases are created. When dictators fall, it usually leads to initial chaos and violence before another elite can establish itself from which a new dictator will emerge.

In her inspired song of praise at the news she would give birth to the long-awaited Messiah, Mary observes how God ‘has brought down the powerful from their thrones and lifted up the lowly’. It is a role reversal typical of St Luke, recorder of Mary’s song, a gift of eschatology many want realised today, not just in the world to come. When the powerful are brought down from their throne today, they are typically replaced by the next most powerful person, and if the throne remains vacant or is contested, what follows often feels like the spirit that went out of a person in Matthew Gospel returning with seven other spirits more evil than itself, meaning ‘the last state of person is worse than the first’.

This need not be a counsel of despair, but a call to informed intercessory prayer which is short on controlling advice for God’s geo-political strategy, and long on the wisdom and patience of the one throne that endures.

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