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.

Review

America

Books

Culture

Politics

2 November 2024

8 min read

James Davison Hunter: diagnosing America’s health

A great experiment is depleted, and nihilism slips into the void.

Roger Standing

Roger is a Baptist minister, author and Senior Research Fellow at Spurgeon’s College in London.

Riot police stand guard outside a White House fence line.

The White House, June 2020.

Angela N., CC BY 2.0, via Wikimedia Commons.

It was unsettling. Disturbing. And in the months since, it has proven to be a powerful and haunting image, etched in my memory. Thinking about it now has exactly the same chilling effect.

So, it was earlier this year. I was at the cinema with a friend, sitting comfortably and waiting for our movie to start. Our shared love of Sci-Fi had taken us there that afternoon. Not unexpectedly, up pops the reel of trailers. Fast paced, dramatic and with loads of loud music, they’re either enticingly engaging or mercifully short.

On this occasion the climax of the reel saw America engulfed in a modern-day civil war. And the image?

A man is pleading, ‘There’s some kind of misunderstanding here, we’re Americans, okay?’

There’s a pause. The music stops. Silence. It’s a long pause.

Then the camera pans to a man in military fatigues, with sunglasses and a rifle sitting ominously on his hip, cocks his head and responds:

‘Okay … [another pause] what kind of American are you?’

Guns cocked, the trailer explodes back into life.

Our movie was really good. My friend’s company, as usual, was delightfully affable. But the image that remains echoes with that question, ‘what kind of American are you?’

I have to confess, I love America. I studied there. I have good friends there. I gorge on American food. I watch American football with my son, every week, on a pay-per-view live stream with real US TV ad breaks (‘Go, Pack, Go!’). In my personal experience Americans are some of the kindest, most thoughtful and most generous of people.

Maybe that’s why I’ve found the image so troubling. Not that it was some kind of fantastical dystopian depiction, but rather that it portrayed something altogether more plausible. Especially in the light of the ‘storming of the Capitol’ on January 6, 2021, the epidemic of mass shootings and the ongoing violent rhetoric on both sides of the political divide.

How do you square the circle of America? How do kindness and generosity sit alongside gun violence? Is the country on the brink of civil war?

Back in 1991 the University of Virginia sociologist James Davison Hunter’s book, Culture Wars: the Struggle to Define America suggested that cultural controversies would be increasingly significant in American politics. At the time not everyone agreed and some even pushed back against such an overblown prediction. Time, however, has vindicated Hunter’s reading of the runes. The ubiquity of his ‘culture wars’ epithet is the proof of his pudding.

Hunter’s latest offering picks up the story once more. Using the present situation in America as a case study, his reflections ‘bookend’ his earlier thinking. However, Democracy and Solidarity is not an extended commentary exploring the rise of populism and the radical right, or the snowflake, woke elitism of the socialist left. Rather, it seeks to understand why the sentence that opens his preface is true: ‘Democracy in America is in crisis.’

Grievance and hurt issue in rage, the unchallengeable moral authority of ‘my personal experience!'

For Hunter, understanding what is going on in a culture requires diving deep into the sources it draws on. What forms it? What drives it? All too easily we focus on the observable and what we can see. The stuff that happens and the values, beliefs and institutions that comprise our common life.

But that is to miss the deeper structures of culture that are formed by our tacit assumptions and the latent frameworks of meaning that nestle unseen and form the cultural architecture that surrounds us. The power of culture is demonstrated by how far it is taken for granted’.

In an interview Hunter likened his approach to be the difference between weather forecasts and climate studies. Or, to put it another way, moving from ‘the politics of culture’ to ‘the culture of politics.’

Beginning at the beginning, Hunter goes to the origin story of the nation. Deeply influenced by the principles of the enlightenment the Founding Fathers of the United States set about their task of nation building. Proposed by John Adams, Benjamin Franklin and Thomas Jefferson in 1776, the national motto on the Great Seal of the United States, E Pluribus Unum (Out of many, one), summed up their political objective. The creation of solidarity. The glue that binds a society together.

The genius of the Enlightenment in America was that it facilitated this solidarity. What was created was a ‘Hybrid-Enlightenment’, fusing the insights of French and British intellectuals in a context deeply influenced by the faith of religious dissenters, with the Puritans chief among them. The blending of the secular and faith insights from the Enlightenment was what provided its robust inclusivity and durability. For Hunter, this proved key because:

“In the end, the hybrid-Enlightenment in America was a broad enough and opaque enough amalgamation to encompass substantial diversity and the tensions that diversity implied.”

This opacity enabled different groups to see themselves in the enterprise and gave wider American society an ability to absorb a plurality of views, opinions, and traditions. A commitment to Enlightenment rationality also then provided the tools whereby differences could be ‘worked through’ in reasoned debate. Thus, the culture was a living thing, growing, evolving and developing. All the time maintaining the wider solidarity, the ‘buy-in’ from the different communities and constituencies that comprise America.

Opacity also meant that tensions and contradictions were part and parcel of the endeavour from the start. There may have been a promise of freedom, equality and universal justice for all, yet historically these have been denied to large tracts of the American population. But still the centre held, and solidarity was maintained. As Abraham Lincoln presciently reflected in his Second Inaugural Address, given on March 4 1865, shortly before his assassination and the end of the Civil War:

“[We] read the same Bible and pray to the same God, and each invokes His aid against the other. … [Yet] the prayers of both could not be answered—that of neither has been answered fully.”

The problem today, as Hunter discerns it, is that the elements of the hybrid-Enlightenment are unravelling. He sees a number of contributory causes to this escalating collapse.

Right at the centre is an amoral, materialistic and individualistic neoliberalism which reduces everything to economics and the market. This is deeply corrosive of community and solidarity.

Then there is the fruit of postmodern scepticism that has filtered down from the intellectuals into the general population. Truth is deconstructed, experts are distrusted and misinformation, disinformation and fake news abound.

Widespread immigration also plays a part. It intensifies American pluralism and brings into the country those who are unfamiliar with the legacy of the hybrid-Enlightenment and for whom the national mythos of America is either strange or incomprehensible. Far from being taken for granted, their worldview does not fit.

The growth of identity politics further complicates the unravelling. Solidarity, rather than being found in the national vision, is achieved by defining ‘us’ over and against ‘them’. It doesn’t foster cohesion, it seeds division. Grievance and hurt issue in rage, the unchallengeable moral authority of ‘my personal experience!’ As with Nietzsche, this acts as a narcotic against the hurt, an anaesthetic for the pain.

Of course, identity politics has no room for reasoned debate and mutual resolution. All that matters is the outcome of the zero-sum game where the justice of my position is both acknowledged and acted upon, and you lose. Whether that identity falls on the political right or left, it doesn’t matter. Family, sexuality, public education, the news media, the arts, the law, electoral politics, you name the issue the game play is the same.

Solidarity always involves drawing boundaries. Even the hybrid-Enlightenment drew the line between what was acceptable and what was unacceptable. Who was a part of us, and who was not. Without boundaries there is no identity. It is just that now, identity politics require the boundaries to be much more tightly drawn. “What kind of American are you?”

In all of this, America’s cultural resources for ‘working through’ these issues have been seriously depleted as the hybrid-Enlightenment has unravelled. Into the void, observes Hunter, a form of cultural nihilism slips in. It is far from being all-pervasive, and he maintains that few Americans are nihilists. Yet as a cultural reality he sees it in the prevailing tendencies towards ‘epistemological failure’, ‘ethical incoherence’ and ‘existential despair’. Then, deriving from these he adds a fourth, ‘political annihilation’ and the will to obliterate everything that obstructs acquiring power by destroying enemies completely.

Does it all seem rather depressing?

Hunter admits that he has neither proposals nor a plan to address the crisis he so eloquently describes and accounts for. Yet he concludes:

“… truth be told, I myself am very hopeful – not because I don’t see the seriousness of the problem and its dangerous implications, but because I believe that the times are full of real opportunity if one has the eyes to see them. Sadly, my eyesight is not very good. … [but] without real images of a better world, without myths of a completion of the past in the future, without a world ordered towards goodness, truth, and beauty … We become something like Nietzsche’s ‘last men’.”

I’m grateful to Hunter. I think I understand my American friends, their country and their present challenges better for his insights. As for the possibility of a civil war, he thinks it’s unlikely as the ‘red and blue’ are too intermingled and economically interdependent across the country. In the meantime, political violence will continue to be a very real threat.

As for the future he hopes for, it requires a paradigm shift to imagine and articulate a new vision of public life. It needs the cultural resources of a reconstituted humanism, drawing on the rich insights available in a genuinely pluralist society. Resources that embrace the faith wisdom of exemplars like Martin Luther King, Mohandas Ghandi and Thích Nhất Hạnh. Resources that include a retrieval of the fundamental principle of forgiveness. Without the realism to accept that none of us are perfect, we’ll never be able to live together. As the influential political theorist Hannah Arendt wrote in The Human Condition (1958):

“Without being forgiven, released from the consequences of what we have done, our capacity to act would, as it were, be confined to one single deed from which we could never recover; we would remain the victims of its consequences forever.”

Arendt’s insight is altogether more telling when seen in the light of her experience as a German Jew under the Nazis. And if forgiveness is too high a bar, at the very least we have to somehow learn to let things go and move on.

Hunter is under no illusions, such a paradigm shift remains a long haul away.

But he is hopeful.