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

Comment

Economics

Politics

Trust

9 April 2025

5 min read

Tariffs destroy trust so where do we go next?

Blunt weapons cause a mess in markets and lives.

Paul Valler

Paul Valler is an executive coach and mentor. He is a former chair of the London Institute for Contemporary Christianity.

A gold coin with the DOGE dog on it, lies over the face on a $50 bill.

So doge-y.

Kanchanara on Unsplash

‘When America sneezes the rest of the world catches a cold’ quipped economists almost a century ago after the Wall Street crash. A comment that might equally apply to the more than 10 per cent drop in stock markets caused by President Trump’s sudden raised tariffs on imports to the USA. The impact of the American economy on the world is inescapable. It represents almost a quarter of global GDP and the dollar is the leading reserve currency, accounting for around 60 per cent of international foreign exchange reserves. Size is what enables America to bully the rest of the world.

For decades the American trade deficit has been an elephant in the room and Trump is to be applauded for recognising it and addressing the problem. Unfortunately, the way he has gone about it has caused another, bigger problem. Changing the direction of the global economy is like turning a tanker, it cannot be done easily or quickly, but Trump’s style is to attack, like hammering at a nail. Every issue in geopolitics looks like another nail, waiting for him to hammer out a negotiated deal. Full marks for courage, but not for wisdom. The blunt weapon of trade tariffs is designed to bring wealth and power back towards the USA, but blunt weapons often cause a mess, and sure enough a global mess is what we now have. A US/China trade war with higher prices that could end up stoking inflation and a government own goal.

Panic selling of government bonds signalling a loss of confidence following Trump’s dramatic tariff boost is reminiscent of the impact of Liz Truss’ sudden and radical UK tax cuts, which were also driven by an ideology, but ended up as a wrecking ball. Even some of Trump’s backers have warned of an economic nuclear winter. In the long run, Trump has done the world a favour by highlighting a structural issue that needed correction, but his economically violent methods of addressing it look increasingly unwise. If a global depression does happen on the back of all this, then coupled with the rise of autocratic and belligerent leadership, we would face a worrying parallel to what happened in the 1930s when the world eventually slid into war.

Tariffs are like walls, barriers to cooperation and the epitome of economic selfishness. Make America Great Again is selfishness writ large - a society pursuing wealth and power without the cohesive framework of values that are so essential to cooperation and community wellbeing. A psychology of self-centredness that damages relationships at the national level. This is what I find most concerning about Trump’s approach; not just the economics but the long-term legacy of relational damage that could last well beyond his Presidential term.

Our fears reveal just how much we trust in wealth above everything else, and how much the fear of scarcity affects our mental health.

Michael Schluter in his book The Relational Lens defines five principles, or measures, of relational health. They are directness, parity, common purpose, continuity and breadth. Applying those five measures helps us see why Trump’s tariffs are the polar opposite of relational. He introduced these escalating penalties remotely and not in face-to-face negotiations. Exploiting the power of America instead of showing respect for the status and needs of other nations. Tariffs have no common purpose with other countries, only a selfish agenda. There is no continuity with previous trading protocols. And it is all purely financial, with no reference to the broader holistic impact. All in all, a relational disaster.

Despite living in the ‘first world’ we remain gripped with fear of loss. Our fears reveal just how much we trust in wealth above everything else, and how much the fear of scarcity affects our mental health. Markets are not entirely rational; they are driven by algorithms that stem from this psychology of greed and fear. Emotions and trading swing wildly with a herd instinct that often drives behaviour. As Rabbi Jonathan Sachs said:

‘Markets have no moral compass; we have outsourced morality to legislation by the State.’

But the worry now is that the current US administration shows signs of ignoring morality and even riding roughshod over the courts. No wonder people feel afraid.

Where can we find hope in all this turmoil? Is there a better response than gritted teeth and the mantra: ‘this too shall pass’? I think so. There is life beyond the market. Jesus said: ‘life does not consist in an abundance of possessions.’ We can choose to step back and look at all this with the true perspective that money isn’t everything. We can cultivate gratitude for what we do have. We can learn contentment. Yet I feel for those who have experienced financial loss, and don’t want to minimise the reality of hardship. In fact, something important and practical all of us who are privileged can and should do is to be vigilant in watching out for those who are poor and disadvantaged. To look after those with a real need for the basics of life and help them through this tough time when economic disruption could make life even harder. For those with a faith this is part of working out how our faith makes a positive difference where we are.

Perhaps the supreme irony of this crisis is President Trump’s insistence that Americans must trust him. Ironic, because the one thing that his tariff actions seem to have undermined more than anything else is trust. The trust that is essential to the functioning of both markets and civilisation as a whole. Face to face discussions must be the way forward now, to rebuild trust and find more nuanced, mutual approaches to solving America’s trade deficit.

There is one person we can always trust though, and his name is written clearly on the American One Dollar bill. In God we trust. Let’s pray that Trump and his America returns to that imperative and turns back to a more Christ centred philosophy of loving our neighbour as ourselves, reflected in a more bilateral approach to diplomacy and agreement.

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