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

Culture

Film & TV

Politics

13 March 2025

6 min read

Fear of the news means it needs to change

Here's how to rethink reporting.

Steve Dew-Jones

Steve is news director of Article 18, a human rights organisation documenting Christian persecution in Iran.

A news cameraman holding a camera, stands back to back to a police officer.

Waldemar on Unsplash.

Several non-journalist friends have told me over the past few years that they have started to disconnect themselves from the news - in some cases entirely - so wearied have they become by the incessant gloom of our reporting.

Meanwhile, new research from the Reuters Institute has found that people have been “turning away from the news” consistently across 17 countries tracked over the past decade - from the US to the UK, Japan to Brazil.

And one of the primary reasons, the researchers discovered, is the “fatigue and overload” of negative news.

Another factor was the declining trust in the media, which has again been something I have heard consistently from friends in recent years, with many telling me they are constantly reassessing who they turn to for news.

Perhaps that is only healthy, but both trends suggest to me that there may be a problem with the way news currently is, and the effect it is having on us.

One of the most regular examples of the “bad news” we journalists tell is the reporting of terror attacks, but whenever I hear news of an attack - whether here or elsewhere - I think not only of the immediate victims and their loved ones, but also those who may soon become victims by association.

Perhaps the most obvious recent example here in the UK was the case of the Southport stabbings, a shocking incident that led to understandable - albeit misguided - outrage.

As soon as it emerged that a “foreigner” - or at least someone who sounded like they might be a foreigner - was responsible, many jumped to the conclusion not only that he was an Islamist but also probably an asylum-seeker, and an illegal one at that.

It later transpired, of course, that the 17-year-old who carried out the terrible attack had been born and raised in Wales - to “Christian” parents, no less. So not an asylum-seeker, after all, nor even a foreigner; and even though it later became clear that he had downloaded disturbing content including from Al-Qaeda, his inspiration seemed to come from a wide range of sources.

Here was another example, our prime minister told us, that showed “terrorism had changed” and was no longer the work only of Islamists or the far-right but of “loners” and “misfits” of all backgrounds, common only in their sadism and “desperat[ion] for notoriety”.

And yet, in the Southport case and no doubt many others, by the time the killer’s background and likely motive finally became clear, the horse had already bolted.

In that particular case, the reaction was especially extreme, with mosques and refugee hotels attacked as part of widespread rioting. But even when there are no riots after such an attack, there can surely be little doubt that the minds of the wider British public will have been impacted in some way by the news.

For some, perhaps the primary response will be increased fear - in general but also perhaps especially of those different from themselves. For others, on top of fear, might they also feel increased hatred, or at least mistrust?

And such feelings will surely only increase with every new reported attack, especially when the perpetrator appears to be someone new to these shores, and even more so, it would seem, if it is an asylum-seeker.

To ignore the reality that many attacks have been carried out by asylum-seekers in recent years is to ignore reality. But for those of us desperate not only to prevent the further polarisation of our society but also to protect the many legitimate refugees who wouldn’t dream of committing such attacks, what can be done?

Perhaps it’s only because I’m a journalist, but in my opinion one major thing I think could help arrest the current trend would be for us to rethink the way in which we do news in general.

Not in order to mislead the public or pull the wool over their eyes - if bad things keep happening, they must be reported, as must the identities of the perpetrators, as well as any trends in this regard - but by way of providing the necessary balance and context.

For example, by looking into what percentage of attacks - here or elsewhere - have been committed by Islamists, foreigners, or asylum-seekers; or considering what percentage of the total population of such groups the attackers represent, and how this compares to statistics regarding other groups.

The question we journalists - and those who read our words - need most to ask is whether we are doing a good job of informing the public about the world they live in.

Might it also be helpful to undertake a general reconsideration of what constitutes news? Does, for example, bad news always have to reign supreme in the minds of those who curate our news cycle?

A decade ago, I had it in mind to create a new app or perhaps even news service dedicated to rebalancing the news, such that bad news stories wouldn’t outnumber the good. Many others have had similar ideas in recent years, and several platforms have been launched, dedicated to the promotion of “good news” stories. And yet one could argue that such platforms risk being as unrepresentative of reality as those that tell only bad-news tales. Can’t a compromise be found?

One of the first things you learn as a journalist, other than that sex sells, is that greater numbers of deaths, and especially those of children, always constitutes headline material. And one needs only to flick through today’s major news outlets to see that this practice remains almost universally upheld. But does it have to be so?

And why is it that some conflicts and injustices will make our headlines, while others won’t?

Take, for example, the Sudanese civil war or the recent beheading of 70 Christians in the Democratic Republic of the Congo. Why is it that these horrors don’t make our headlines, while tragedies in Ukraine or Gaza do? Who makes the call, and for what reasons?

Another long-established principle in journalism is to consider first and foremost who your audience is. So, for example, when writing for a British audience, to consider what might be of most interest to Brits. Are Ukraine and Gaza, for example, simply more relevant to British interests - in both senses of the word - than what is happening in the Global South? And even were that to be true, just because such principles of journalism are long-established, must they remain unchallenged?

At its core, journalism is about informing, so in my opinion the question we journalists - and those who read our words - need most to ask is whether we are doing a good job of informing the public about the world they live in.

And in my view, while a lot of good journalism is of course being done, the question of whether the public are receiving a representative picture of their environment is less clear.

Whether or not the best approach to redress the balance is to dedicate whole news services to telling good-news stories, there’s surely little doubt that such stories are chronically underreported.

And if our duty is not only to inform but also, by virtue of that, not to mislead, mightn’t it be argued that in failing to sufficiently well inform society about the real state of our world, we are in fact misleading them?

No-one wants to end up in a Soviet-style “paradise” in which murders are simply denied in order to maintain the status quo, but nor, surely, do we want to live in a world in which people become unnecessarily fearful and hateful towards others, in part because of the news we feed them.

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