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.

Article

Change

Politics

Psychology

5 November 2024

5 min read

How to be a wise diplomat about the election result

It’s not just American citizens weighing-up and trading-off.

Emerson Csorba

Emerson writes on geopolitics. He is also a business executive and holds a doctorate in theology.

An ambassador presents credential to President Trump

President Trump accepts credentials from Indonesian ambassador M. Lutfi.

White House via Wikimedia Commons.

The American election result, whatever the case, is a landmark event in geopolitics. And here, it is unclear which result is better for the world in the long-term, given the ambiguous motives, interests and intentions of its main characters.

Whereas the Biden Administration led by the Democrats has been fraught with war, the Trump Administration was comparatively peaceful, with breakthroughs such as the historic Abraham Accords. Yet, the rhetoric of President Trump is aggressive and divisive.

Despite mainstream media assertions focused on the clear best choice in the election, a balanced perspective is necessary involving consideration of trade-offs between what the parties and their leaders each offer. This balance, however, is difficult to achieve as polarisation encourages retrenchment into simple views.

As the American election approaches, it is worth considering what a diplomatic approach to an election transition might entail. Here we can look to the example of Henry Kissinger, whose diplomatic mindset is illustrated in Barry Gewen’s The Inevitability of Tragedy. Gewen eloquently illustrates the Kissingerian – even if often cold-hearted – approach to the consideration of trade-offs in diplomacy.

Gewen traces the early-life experience of Kissinger, a German Jew forced to flee Nazi persecution, both serving in the US Army and attending Harvard. Unlike his American peers, Kissinger understood through personal experience that authoritarianism could rise through democratic means, Adolph Hitler the primary example.

It is partly for this reason that Kissinger was willing as US Secretary of State to intervene in the affairs of foreign states to halt dictators emerging through democratic processes. The trade-off was here between respect of democratic process and the possibility of dictatorship, a trade-off which Americans without German-Nazi experience would never understand and which they saw as deeply unsettling.

Kissinger is the archetypal diplomat. His example is worth reflecting on in the wake of the American elections. Kissinger approached geopolitics with little emotion, instead considering what course of action in a particular situation served as the least worst evil available.

He engaged across a wide variety of networks, talking with individuals who would not speak with each other. And he maintained a considerable sense of calm throughout his career as both an actor and commentator, responding to events as they developed.

An initial consideration in emerging from the American elections is that too much emotionality – amplified by political polarization – will expose politicians, diplomats and the public to risk. Emotion colours careful, strategic calculation of various scenarios and actions across potential scenarios.

‘People constantly show you who they are; we are just too busy to notice,’

An effective diplomatic (or strategist) will carefully consider what might happen and think through potential steps in case these realities actually transpire, while recognising that too much anticipation risks cascading into fantasy. Too much emotion impedes this careful process of reflection and deliberation as part of the development of strategy.

A second element of effective diplomacy and strategy is to consider people as they are, rather than rely on superficial descriptions in the media, biased second-hand accounts or who or what one hopes another person is. People’s motives, intentions and interests are not easily discernible at first glance, instead requiring careful probing and questioning.

At the same time, there are few more accurate sayings than ‘People constantly show you who they are; we are just too busy to notice,’ conveying that counterparts are always providing information as to who they are, few careful or disciplined enough to mask their real thinking.

An effective diplomat might consider the early upbringing – much like that of Kissinger – that shapes a person’s character and behaviour, if not their worldview informing action.

Consider Donald J. Trump, learning right from wrong on the streets of New York City via the mentorship of lawyer Roy Cohn, who served as Chief Counsel to Joseph McCarthy while McCarthy prosecuted potential American communist sympathisers.

Cohn’s rules of life, work and play were as follows (these summarized by a friend well-acquainted with Cohn and his colleagues): ‘One, attack, attack, attack! Two, deny everything! Three, always claim victory!’ The logic of these three rules of life are readily understandable when considering the harsh New York realities within which Cohn and later Trump operated.

These considerations are overlooked, however, amid the onslaught of media which fails to consider what really shapes the character of a man or woman.

Curiosity, a critical mindset and self-restraint in the face of the human temptation to reach rapid and satisfying answers are here necessary, as part of figuring out what exactly is driving action.

A wise diplomat would pay particular attention to these pivotal factors – such as the influence of a long-standing mentor or advisor – as they might manifest in the present. This requires an intellectually honest and serious consideration of the worldview that shapes a counterpart, rather than considering superficial media commentary.

Third, a wise diplomat will maintain relations across a wide variety of networks, understanding that it is fine to talk with two or multiple individuals whose own relations are fractured (in fact, these strains in relations can be beneficial within diplomacy, the diplomat in this case able to play broker as he or she needs or wishes).

The maintenance of broad networks is vital, because this enables action under a wide array of potential circumstances, understanding that anything can happen (we are here reminded of Harold MacMillan’s saying “Events, dear boy, events!”) And a key lesson in diplomacy and in the cultivation of strategy is that, once crises unfold, it is the preparatory work in developing networks and alliances that counts; little new network-formation is possible afterwards.

The previous two points suggest that a wise diplomat will not pay too much attention to what is in the media, but will instead consider their own learning gleaned through in-person interactions with others, as well as the perspective of their most trusted contacts. Curiosity, a critical mindset and self-restraint in the face of the human temptation to reach rapid and satisfying answers are here necessary, as part of figuring out what exactly is driving action, and what can in turn be done to shape action in accordance with interests.

Finally, an effective diplomat will not try to play God, serving as the arbiter of right or wrong, adopting instead a more considered approach anticipating and responding to circumstances as they gradually or quickly evolve. Effective strategy requires an aloof approach (caring – but not caring too much), removing the self from a given situation so as not to allow natural human vices such as presumptiveness, arrogance or short-term self-interest to affect judgment.

And the American election bring with them a number of trade-offs, these to be weighed carefully by American citizens, as well as by diplomats and strategists in other countries. These trade-offs will be considered most effectively if approached with calmness – the aloof, even if cold-hearted, approach personified by Henry Kissinger.

In an age of catastrophising, emphasing emotion, it is easy to descend rapidly into despair, rather than consider action from a long-term perspective. Diplomacy and strategy require the latter, which will be a key to success for those who emerge effective in advancing their interests in the wake of the American elections.