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

Belief

Creed

Politics

27 October 2025

7 min read

If a King can pray with a Pope, can MAGA and Woke ever talk?

Once bitter enemies found peace through prayer - offering a quiet challenge to today’s culture warriors

Graham Tomlin

Graham is the Director of the Centre for Cultural Witness and a former Bishop of Kensington.

The Pope and King Charles walk together from the Sistine Chapel

Royal.uk

Last week, King Charles met the Pope.

There was a part of me that wondered what Martin Luther, Thomas Cranmer, and even the young Ian Paisley would have of made it. Not much I imagine. The days of sharp theological barbs thrown between Protestants and Catholics over the mass, purgatory, the place of Mary, praying to the saints and so on are largely over. I imagine they had a cup of tea, admired Michaelangelo’s painting in the Sistine chapel and had a chat, but the main thing they did was to pray together - the first time a British monarch had met to pray with a Pope since the Reformation.

So this was quite a big deal. Prayer carries much more significance than tea. But why did it matter so much?

To make sense of it, you have to remember the history.

In the aftermath of the English church’s break from Rome under Henry VIII, later consolidated under Elizabeth I, one of the most influential books that emerged from the English Reformation was Foxe’s Book of Martyrs, originally published in 1563. Alongside the ubiquitous King James Bibles, copies were to be found in English homes up and down the country for centuries afterwards. The book was a grisly catalogue of Christian persecution down the ages, and a thinly veiled side-swipe at the author’s main target - the Roman Catholic church, or “popery, which brought innovations into the church and overspread the Christian world with darkness and superstition.” Back then, that was how most British people saw the papacy.

In 1605, a plot led by a group of English Roman Catholics to kill King James I of England (and VI of Scotland) and to blow up the Houses of Parliament was rumbled – the infamous Gunpowder Plot. For centuries afterwards on the anniversary of the conspiracy (until Health & Safety and modern squeamishness toned it down) the English lit bonfires, launched fireworks, and burnt effigies of the Catholic plotter Guy Fawkes to celebrate the deliverance of the nation from papal tyranny. At the time - and partly as a result of that event - Catholics were feared in England much as militant Islam is today in parts of the west – as a shadowy force infiltrating the nation from other European countries (mainly France and Ireland in this case), intent on changing the religion of the country, and imposing arbitrary and tyrannical rule on the population of Britain.

Later in the same century, the looming prospect of a Catholic monarch put Britain into a spin. Charles II had been restored to the throne in 1660 after his father’s execution during the Civil Wars. Charles’ own Protestant credentials were always shaky – a fear that was confirmed by his deathbed conversion to Catholicism in 1685, but at least during his lifetime he remained a Protestant Anglican. The real problem was the heir – Charles’ younger brother James, the rakish Duke of York who was most definitely a Catholic. The same fears of papal tyranny and arbitrary rule, taking away the precious freedoms of the British people were the talk of the coffee houses and broadsheets of the 1670s and 80s.

All the more remarkable then, that relationships between Anglicans and Roman Catholics have develop to such an extent that Anglicans (alongside other churches) were guests of honour at the late pope’s funeral and the inaugural mass of the new pope - and a King prays with a Pope.

So why have things changed so much?

Part of the answer is that times have changed. Europe is less obviously Christian than it was back then. The Christian churches have realised they don’t have the luxury of fighting over such matters. With Christian theology becoming less of a ‘public truth’ that held nations together (much as notions of freedom and democracy do for us today) arguments over it became less fraught and charged.

Another reason is the lengthy conversations that have taken place between churches in the ecumenical movement throughout the last century that have carefully been able to unpick the disagreements, clarifying what was and wasn’t at stake in the fights between Lutherans, Catholics, Anglicans, Orthodox and others. These conversations haven’t solved all the issues. Different Christian denominations still disagree on a lot, especially today on issues like human sexuality and the like, but over time, they have at least brought clarity and a certain harmony to some of the historic disagreements. Anglicans still convert to Catholicism, and Catholics become Anglicans (or Orthodox or Pentecostals). The King and the Archbishop of York could not take Holy Communion with the Pope, but they could pray. I know from personal experience the depths of friendship that come when you recognise a brother or a sister in a Christian that you disagree with but in whom you can still recognise an essential commonality.

Another key part of the answer is that the Roman Catholic church has changed. Last year for example, the Vatican department that oversees relationships with other churches issued a study document called ‘The Bishop of Rome’. It was part of an ongoing conversation between the Roman Catholic Church and other world churches on the role of the Pope in the modern world. It talked about the Papacy as having a ‘primacy of service’, its authority linked not to the triumphant but the suffering Christ, of how the Pope offered a kind of ‘personal’ kind of leadership, Orthodox churches a ‘collegial’ form (led by groups of bishops) and the Protestant churches a form that stressed the importance of the whole community.

In other words, here was the Vatican asking other churches how the Papacy can be a help and support to Christians around the world. Back in the nineteenth century, in the first Vatican Council of 1869, the language was very different. The papacy was there by ‘divine right’, essential for the church, implying that other churches really ought to come back into the fold of the Church of Rome. The Roman Catholic church now seems to take a humbler, more generous stance which makes it possible for a King to pray with a Pope again.

It's a heartwarming story. We constantly lament today the polarised, fragmented and angry nature of our politics and our cultural debate. The ecumenical movement of the Christian churches over the last hundred years may not be the sexiest development in recent cultural history. It involved long and painstaking conversations, the building of friendships and relationships across suspicion, a willingness to see the good in the other even when you could not agree. Yet this combination of time, patient conversation and humility has yielded fruit.

In the seventeenth century, British Protestants saw Catholics as the deadly enemy seeing to undermine everything they hold dear - pretty much as some people do today see Muslims, or as progressives see conservatives or vice versa. Does this story hold out any hope of finding healthier ways to live together across our religious and political divides? Maybe. It's different of course because Catholics and Anglicans share the same basic faith, they recite the same Creed, they read (almost) the same Bible, they worship the same Jesus. With Islam we're talking about a different faith altogether. The ‘woke’ and the ‘MAGA’ people don’t seem to share much at all.

But yet we do share a common humanity. And with patience, conversation, a willingness to look for the good in the other, some form of peaceful co-existence, with freedom to debate, or even to change religion might become possible.

For that we can hope. And like the King and the Pope, pray.

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