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.

Essay

Comment

Economics

Sustainability

18 November 2024

8 min read

Raiding the fields, lessons from history

A tax raid on farmers is raising more trouble than revenue.

Theodore Brun

Theodore is author of the historical fiction series The Wanderer Chronicles. He previously studied Dark Age archaeology at Cambridge, and afterwards worked in international law.

A soot stained burnt-out harvester sits in a recently harvested field.

A burnt-out harvester, Lonesome Farm, Oxfordshire.

Nick Jones.

“Better red than expert.”

That was one of the slogans touted through the national propaganda channels in the early days of the People’s Republic of China shortly after Chairman Mao came to power. In other words, professionalism should be subordinated to politics.

It seems a pretty accurate description of the current UK government’s own attitude to farming in the light of their controversial inheritance tax raid on the nation’s farmers. Prior to last month’s budget, Agricultural Property Relief meant that farmers could expect to hand all qualifying agricultural assets on to the next generation without lobbing their children the simultaneous hospital pass of a whopping great tax bill. It was this inheritance tax relief and this alone that allowed every typical asset-rich/cash-poor farming business to survive as a going concern from one generation to the next.

Chancellor Rachel Reeves, perhaps applying her “better red than expert” thinking, identified this as a tax loophole that needed to be closed. She says it is costing taxpayers £1billion a year - which, when you think about it, is like a man who’s just cornered you in a dark alley saying you are costing him and his mates £100 by keeping those two shiny fifty pound notes in your own pocket.

Farmers will now be expected to cough up 20 per cent of the value of their agricultural property into the national coffers with every passing generation. It doesn’t take an expert mathematician to realise such an erosion of capital needed to pay these bills will render many farming businesses untenable, particularly given that farming relies heavily on economies of scale. This represents a torpedo strike on the farming industry which will sink a very large number of people, not just so-called Barley Barons.

No matter that the uptick of increased annual tax take from this measure will barely be enough to cover a day and a half of the NHS spend. Nor that while the government claims that, with a threshold of £1million before inheritance tax applies, 72 per cent of “farms” will not be affected (their definition including small parcels of land, and so-called toy farms which make no pretence to be food-producing businesses), the National Farmers Union says the true figure is closer to the inverse of that.

John McTernan, a former aide to Tony Blair and supporter of current PM Keir Starmer, didn’t help cool tempers with his revealing comment that farming was an industry which the UK could do without. “Labour can do to farmers what Margaret Thatcher did to the miners,” he said. Starmer was quick to distance himself from these incendiary remarks.

But as farmers would no doubt appreciate, what looks and smells like horse manure, probably is horse manure. And these measures are what they look like: an outright attack on the farming community, and more widely the ancillary rural economy which farming supports. The average farmer would be forgiven for thinking this feels far more ideological than fiscal in its aims.

That is why this week will see the largest rural protest in Westminster since the Countryside Alliance march in 2002. Farmers will converge on the Houses of Parliament to ask the government to reconsider such a direct attack on the food security of this country.

Given this fraught situation, are there any lessons to be learned from the past?

You have to wonder whether arguably the most left-wing government this country has ever seen is taking ideological plays out of the history book. Such tax raids on farmers' fields are nothing new. From ancient biblical times even to the last one hundred years, the consequences effect much more than the economy, they reach even to the soul of nations.

If farmers as a community stand in the way, what is the objective that lies beyond them, which the new utopians hope to attain?

In 1920s Russia, the Bolsheviks specifically targeted a class of landed smallholders known as the Kulaks.

The Kulaks were relatively prosperous, independent farmers, who faced severe repression during the 1920s and 1930s under Stalin's Soviet government. Originally benefiting from land reforms after the Russian Revolution, they were seen by Stalin as a threat to his goal of collectivizing agriculture. By labelling the Kulaks as "class enemies" of the working class, Stalin launched a campaign to liquidate them as a class around 1929, aimed at confiscating their land and redistributing it to state-owned collective farms.

The Soviet government seized Kulak farms, livestock, and tools, often forcibly relocating families to remote regions or sending them to labour camps where many perished due to harsh conditions. This campaign fuelled widespread suffering, triggering famine, especially in Ukraine, where it contributed to the devastating Holodomor. By the early 1930s, the Kulak class was effectively destroyed, resulting in millions of deaths and lasting trauma across the Soviet countryside.

Or how about China?

During China’s Cultural Revolution (1966–1976), smallholders and farmers faced severe disruption as the government under Mao Zedong sought to enforce collectivization and reshape rural life. Although China had already implemented collectivization during the 1950s, the Cultural Revolution intensified the suppression of individual farming and private land ownership, pushing for even greater alignment with socialist ideology. Farmers were forced into collective communes where land, equipment, and resources were shared, and individual autonomy was abolished.

Many were publicly humiliated, re-educated, or sent to labor camps. In addition, the chaos of the period meant that agricultural expertise was disregarded, as revolutionary fervour prioritized political ideology over practical farming knowledge. The mismanagement of agriculture, paired with forced collectivization, led to poor yields and food shortages, further destabilizing rural areas and causing hardship for millions of farmers and their families.

None of this is very encouraging for farmers in twenty-first century Britain. Especially when one considers how ideologically-driven Keir Starmer truly is, if his contributions to back issues of the magazine “Socialist Alternatives” in the early 1990s are any indication.

But if the socialist goals of the twentieth century were collectivisation and the social engineering of class warfare, what could they be today? If farmers as a community stand in the way, what is the objective that lies beyond them, which the new utopians hope to attain?

Again, it doesn’t take an “expert” to hazard a guess. Ambitious government plans to iron-clad the countryside in solar panels and wind turbine farms in a drive towards net zero will be made considerably easier once the current landowners are forced to flood the market with cheap land in order to service a hefty inheritance tax bill. All to save us from imminent environmental Armageddon.

As they listen to what farmers have to say this week, Keir Starmer and Rachel Reeves might do well to reflect on the fate of Jezebel and her king.

This is a narrative that some can at least imagine. But perhaps that is straying too far into what most would consider conspiracy theory at this point, so let’s back up a little.

All the same, when a wrong of this magnitude is done to a particular group of people - especially one made up of some of the most dependable, uncomplaining, and hard-working members of society, it seems reasonable to ask the question: Cui bono? Who benefits from this wrong?

For the answer to that, we shall have to wait and see how it unfolds.

But in the meantime, it is worth considering a perspective from even deeper in the past. A perspective on the “good” that comes from the ownership and stewardship of the land, especially land seen as a family or tribe or nation’s inheritance. With powerful stories set amid ancient fields the Bible has much to say on the matter.

In a sense the whole of the Old Testament is concerned with this question. God gives Adam and Eve land to steward and cultivate. And then expels them from it as a consequence of their sin. From Abraham until Israel’s exile, the story of God’s chosen people is profoundly linked to a promised land which is first placed in their hands as a blessing and means of sustenance and support - of life itself. An inheritance to be preciously held, stewarded, and passed on from generation to generation. And yet which is taken away again by the hand of God’s judgement when Israel turns away from its Lord and Sustainer.

But consider just one story for a moment: that of the humble farmer Naboth and his little vineyard, described in the first book of Kings. This provides an eerily close analogy to the UK government and its current land grab. It is both powerful and chilling.

One day the state, in the form of King Ahab, decides it would rather like Naboth’s vineyard for itself. Ahab offers Naboth money for it. Naboth refuses, saying, “The Lord forbid I should give you my inheritance.” Ahab - “vexed and sullen” - rages in frustration, until his wife Jezebel concocts a far more cunning scheme to get him that land, involving lies, slander and ultimately murder. There’s a twist in the tail, though. Once Ahab has what he wants, God sends his prophet Elijah to denounce his wrongdoing and warn him of his (rather grisly) coming fate.

For those with half an eye on the unseen as well as the seen in this country, the introduction of this family farm tax at this time may come as no surprise. Many in the church have perceived the “spirit of Jezebel” as ascendant on a number of cultural fronts at this moment in our history.

For Israel, the reign of Jezebel was a dark and uncertain time. And for farmers protesting on Tuesday, they may feel this is no less a dark and uncertain time.

As they listen to what farmers have to say this week, Keir Starmer and Rachel Reeves might do well to reflect on the fate of Jezebel and her king.

And for their part, farmers might reflect on the blessing of the inheritance they have received; and what, like Israel before them, they may have done - or not done - in the eyes of God, to jeopardize their chance to pass it on.

After all, at this point in the story, it’s not too late for either side in these farm wars to turn back.