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

Death & life

Digital

Easter

17 April 2025

4 min read

Do you have a right to be remembered?

Our desire to be in control might not survive our demise.

Jack Nicholson

Jack is a graduate of Peterhouse, University of Cambridge and Blackfriars, University of Oxford. He writes, and also works in local government.

A composite show a smiling woman next to a small illustrate of someone walking off into the distance.

Kristyna Squared.one on Unsplash .

“Madam, those that are about to die salute you.”

Words attributed to Roman captives and criminals fated to die before the emperor, were used (ironically) by Councillor Kieron Mallon at the last Council meeting of this term of Oxfordshire County Council last week. ‘Madam’ was the Council’s Chair, wishing everyone well. Elections are on the way.

Easter is also on the way, and in the period leading up to the commemoration of the resurrection of Christ from the dead, nearly 2,000 years ago, Christians are invited to think about their own mortality. ‘Remember that you are dust, and to dust you will return’ were words my priest intoned to me as he marked a cross with ashes on my forehead on 5 March, Ash Wednesday.

Ash already emblemizes a belief in rebirth, even before the power of the story of the Christ’s resurrection is considered. I for one felt immensely hopeful on Ash Wednesday this year. Having just secured a new place to call home, and one year into my job as Democratic Services Officer to Oxfordshire County Council, looking after the likes of Councillor Mallon, life felt pretty swell.

My priest and I spoke about the ways in which death and hope are joined at the hip. The ancient Greeks believed that a phoenix obtains new life by rising from the ashes of the one before it. So do we. I have found myself, so far this year, visiting people and places I strongly associate with former lives, from friends I lived with as an undergraduate to a town I went on holiday as a child to the beach where my late Granny’s ashes were scattered. ‘Ashes to ashes, dust to dust.’

More specifically, the Christian believes that ‘whoever loses their life for [Christ’s] sake will find it’, in the sense that true self-discovery arises when we let go of the ego, when we allow ourselves to be changed. Thinking about mortality, therefore, changes life, in so far as we are better equipped to surrender and salute the Saviour. That worldview has shaped public servants in years gone-by.

An overwhelming majority of people in the course of human history have been forgotten.

I recently heard Dr Ian McGilchrist, the psychiatrist, describe the desire to control everything in life as the ‘besetting sin’ of the age in which we live. The desire to be remembered, rather than reborn, captures it better in my mind. Mankind has always wanted to remain in control. Souls will always be reluctant to surrender. However, what we have now is a world in which people feel uniquely entitled to make impact.

People feel that they have a right to be remembered, but it is not so. An overwhelming majority of people in the course of human history have been forgotten. Moreover, the past can be especially compelling when we have a window into a world in which people did not necessarily expect to make any kind of worldly impact whatsoever. Theirs was a happier place.

The twentieth century was described by Philip Rieff in 1966 in terms of the ‘Triumph of the Therapeutic’. He wrote, ‘Religious man was born to be saved’, but ‘psychological man is born to be pleased.’ ‘Psychological man may be going nowhere, but he aims to achieve a certain speed and certainty in going’. Therapy enables that objective. But therapy to what end?

Counselling can be construed as a device to regain control. The counselled, if fixed, can go about trying to change the world, trying to make an impact, resuming the rather pleasing but never-ending mission to be remembered. For anyone of a religious sensibility, however, that is not the objective. Rather, new life is given only for the whole resurrection story in our own lives to be repeated.

Around the time that Rieff wrote his book, the historian Herbert Butterfield, a Christian, wrote this. ‘Those who lived when the world was static – when the silhouette of the ploughman against the horizon hardly changed in the passage of a thousand years – may have something to teach us, who only know a breathless, rapidly changing world and who seem to be having to pluck what we can from life while running at full speed.’

Social media has surely exacerbated this condition because it connects us to others at the cost of contemplation about what life – and death – really entails. It is a place where we try to evidence to others the impact we are having, where we write our own eulogies and our own epitaphs and have access to the whole world whom we expect to read the same.

Life changes to a much greater extent these days, in this place, than it did for the ploughman in the passage of a thousand years, or captives and criminals in the Roman world, including Jesus Christ who was identified as one such. However, if we can somehow create conditions to focus less on having impact in and on a volatile world, and being someone who ought to be remembered, we will find that we have more hope.

In turn, we will change the world for the better, but despite ourselves, and for me that is what this period leading up to Easter is all about. We may find that others who are about to die salute us too, for the good deeds we have done that may well be forgot.

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