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

Books

Culture

Economics

Politics

8 April 2025

5 min read

Abundance and the attempt to build a better world

Is this policy the antidote to the zero-sum game of politics?

Josh Richards

Josh is a curate in London, and is completing a PhD in theology.

Construction worker climb a steel framework.

Josue Isai Ramos Figueroa on Unsplash.

What do you do when more money won’t solve a government’s problems? Abundance: How We Build A Better Future, the new book by Ezra Klein and Derek Thompson is an extended polemic against a form of government—particularly as practiced by US liberals—that stymies policy delivery. However technocratic that sounds (and the book often is), it forces readers to confront deeper questions about the nature of politics.

At the heart of the book is a critique of what the authors, drawing on the film Everything Everywhere All At Once, call 'Everything Bagel Liberalism'. In the film topping are added to bagel to the point that it becomes a blackhole. So too, Klein and Thompson suggest, with so much well-intended policy, in which in seeking to tick every possible box and satisfy a range of regulators it becomes a delivery blackhole and little is actually done. The authors ask whether parties of the left are focused on measuring spending to the exclusion of measuring what gets built.

The first chapter gives a good sense of their approach.  It tells a familiar story about the way in which so many are being priced out of cities because of a lack of affordable housing. However, in doing so, it highlights a surprising harm: that geographical proximity remains an important enabler of technological innovation so a lack of affordable housing in cities means a loss of creativity.

The diagnosis is perhaps even more surprising coming from American liberals. Special interests—including those seeking to protect the value of their own houses—weaponize interlocking sets of well-intentioned legislation to prevent homes being built. Subsequent chapters apply that similar logic—regulation and a lack of focus resulting in inaction—to infrastructure, government capacity, scientific research and the implementation of new inventions.

The book's strength is that it is not particularly detailed in its policy proposals. Klein and Thompson instead offer abundance as a lens through which policy development can be viewed: what do we need more of and how do we get it? This lens can be applied from within a wide range of ideological frameworks. It is not itself a worldview but a challenge that any politics should be obsessed with effective delivery not simply desiring the correct end-state.

The book is unapologetically focused on America and the failures of progressive governance, particularly in California. (One of this book's peculiar legacies will be to leave many who have never been there perpetually invested in California's struggles to build high-speed rail.) Nevertheless, the approach already has its advocates in the UK - for example, the Centre for British Progress which set out its stall last week, and it is not hard to see how an agenda here that could be seized by a less hesitant Starmer government.

Any plausible political analysis must hold together the reality of scarcity and abundance. Losing sight of either unmoors us from the actual world we find ourselves in.

Indeed, perhaps the book might feel more realistic if it had other countries in mind. Reviewing Abundance, Columbia economist Adam Tooze describes the book as painful to read, characterising it as a manifesto for the Harris presidency that never was. Indeed, according to the authors, the book was originally scheduled for release in summer 2024 to influence the Democratic platform leading up to the 2024 elections. Instead, it appears in 2025 amid Trump's assault on institutions, Tooze's Columbia among them.

In an interview on Pod Save America, the authors argued that the book is still relevant, offering a framework with which Democrats can oppose Trump. Thompson described the Trumpian view of politics as fundamentally shaped by scarcity. He suggests that behind 47th president's policies—most notably the tariff agenda—is the conviction that every interaction is zero-sum; for you to gain, I must lose.  On this analysis, the way to oppose a politics that pits groups against one another over limited resources—housing, trade, jobs—is to figure out how the government can provide more and argue for it. In its critique and its hopefulness, Abundance offers those who believe in institutions a way to navigate—even work with the grain of—the anti-institutional temperament of contemporary politics.

There might be something to this messaging, but scarcity plays an unmissable role in Klein and Thompson's argument. Remember that they characterise what they oppose as "Everything Bagel Liberalism", policy that tries to achieve every outcome and loses focus in doing so. They may conceive scarcity differently to Trump, but their book is a warning policy cannot deliver as much as we think. It is a call for us to oppose, to compete against those special interests—whether they be residents’ associations wanting to hold up house prices or politicians wanting to cut research grants—whose policy priorities overload the bagel.

At heart, the book is a reminder that ultimately the salient scarcity in politics is not housing or trade or even money. It is time. Abundance cautions governments that unfocussed policy yields the time entrusted to them by the governed.

Humans cannot lead politics completely beyond its zero-sum logic. The world is so often a violent competition over resources and government must restrain that violence while avoiding being co-opted as a means of exploitation. And yet, politics is also—even primarily—an avenue through which communities answer a primal summons to be fruitful, abundant.

Ultimately, any plausible political analysis must hold together the reality of scarcity and abundance. Losing sight of either unmoors us from the actual world we find ourselves in. Yes, there is so much broken and warped to reckon with, and we must grapple too with our finitude’s bluntness, but so too is creation replete with goodness, among them our capacity to invent and deliver what we need together.

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