Article
Assisted dying
Comment
Politics
7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

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
Character
Comment
Friendship
Virtues
4 min read

As algorithms divide us, who should we be loyal to?

An ethicist’s answer, shows we need courage and wisdom too.

Isaac is a PhD candidate in Theology at Durham University and preparing for priesthood in the Church of England.

Three people sitting looking out over viewpoint are silhouetted against the sky.
Priscilla Du Preez on Unsplash.

What is loyalty? As we plunge into this new year of 2025 it seems as pressing a question as ever. The war in Ukraine rumbles on, a fresh Labour government continues to struggle with public opinion, and America returns to the unpredictable rule of the first president in its history to be a convicted felon. The algorithms of social media continue to segregate and amplify different audiences into ever more closed feedback loops and echo chambers. This may bolster loyalty to a point of view, but estrange us further from our friends and neighbours whose loyalties lie elsewhere. All of these and many other cases highlight the conflict of loyalties in our society and wider world. What is even more obvious is that if we are to make peace, cultivate love for enemies, and pursue the common good, then perhaps the most in-demand virtue of 2025, at the top over every wish list, might just be loyalty.  

But what really is loyalty?  

I was struck by a persuasive answer given by Dr Tony Milligan, research fellow in philosophical ethics at King’s College London, during his appearance on a recent episode of The Moral Maze on BBC Radio 4 that asked ‘is loyalty a virtue or a vice?’ He said loyalty is, “Sharing another person’s commitments and the willingness to go through various kinds of adversity in order to pursue those commitments and to further them.” Under cross examination and asked if loyalty is then an absolute virtue he responded, “I think that it’s absolute in the sense that we absolutely need to have it, that it’s basic to the human condition and not optional.” His second interrogator, Giles Fraser, then suggested a ‘high doctrine of mates’. In this doctrine you are loyal to your mates in all circumstances, even if they are ‘wrong-uns’. Dr Milligan’s response, when asked how he would characterise this ‘doctrine of mates’ position, was fascinating: “Addiction.” Fraser then asked if that addiction could be love. “It’s a case of love, and we don’t get to choose the people that we love. We find ourselves in the predicament and then try to make the best of it…I love my wife Susanne, I’ve been with her 31 years, and it’s love, and it’s also addiction. I just can’t envisage a world in which I would be without her.” This framed Dr Milligan’s final powerful point: love, and the loyalty which love entails, gives us our sense of value.  

I can bear witness to the truth of Dr Milligan’s intertwining of love and loyalty. Last autumn I became a father for the second time. My love for my eldest is so great that there was a real question: ‘if my love for my eldest is so total, so all encompassing, how can I possibly love a second as much?’ This question melted away as I gazed into her screwed-up face, moments after she entered the world. I am completely dedicated to ensuring that she flourishes and I would “go through various kinds of adversity in order to pursue” her flourishing. As Dr Mulligan also said, loyalty “is basic to the human condition and not optional.” Of course, how this total and non-zero-sum loyalty of love to both of my children actually works in practice requires of me thoughtful negotiation. If one wants to go to the park and the other wants to go to the swimming pool I cannot split in two and do both things at once. Loyalty, as finite human beings, requires wisdom in living in the middle of a messy network of demands and desires, of the preferences and needs of others. 

If loyalty is then one thing, it is the willingness to recognise that we are tied to other people, whether we like it or not. Cain’s question to God, when God came looking for Abel, is still pertinent: “Am I my brother’s keeper?” Perhaps the greatest disloyalty is the implied ‘no’ in Cain’s rhetorical question. In denying that he is bound to his brother he is disloyal not only to Abel, but to himself because he denies his own humanity and isolates himself from the humanity of other people. If we isolate ourselves, having loyalty only to ourselves, we lose the joy of being fully human. If we simply kill those we dislike, whether literally (in war or murder) or metaphorically (‘unfriending’, cancelling, pretending they do not exist), then we follow Cain. Loyalty, as the tie that binds us to the messiness of the real world where people vehemently disagree all the time, requires not only wisdom then but courage also. It takes courage to commit to one person in marriage. It takes courage to raise a child. It takes courage to continue to talk with and to love those with whom you deeply disagree.  

When practising our 2025 New Year’s resolutions let us make sure that amongst the commitments to get back to the gym and practice that new hobby that we remember to practice loyalty. Loyalty not only to those we love, but to those we might come to love. Let us be wise enough and brave enough to be fettered to those with whom we disagree, loyal to the humanity that binds us together.

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