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

Books

Comment

Film & TV

Morality

27 August 2025

6 min read

Murder we wrote: how cosy crime and psycho-thrillers carve our minds

Our reactions have changed from heart-wringing cries to merely puzzle-solving

Theodore Brun

Theodore is author of the historical fiction series The Wanderer Chronicles.

Elderly amateur sleuth stand by their pinboard.

The Thursday Murder Club convenes.

Netflix.

We love murder.

That seems to be the only reasonable conclusion when you look at the sales figures of Richard Osman’s record-busting murder mystery series, which opened with The Thursday Murder Club back in 2020. In UK sales alone, it sold over a million copies within the same year as its release, something no other book has ever done.

This was more than a bestselling debut novel, this was a cultural event in UK publishing. And no doubt Netflix are hoping for something equally seismic when their film adaptation of The Thursday Murder Club goes live.

The combination of light humour, a clutch of charismatic octogenarians, tea and cake, and the odd violent death or two to keep them entertained, seems to have struck the motherlode of British cultural appeal. I can only imagine the stellar cast they have assembled for the film adaptation, led by Helen Mirren and Pierce Brosnan, will take the series’ success to new heights.

As an author currently puzzling my way through my own contemporary murder mystery, I can only look on at the phenomenon in wonder and sigh for what may yet be.

But murder has always been a tricky one for me as a) an author, and b) a Christian. Do those two facts mean I have to be a “Christian author”? And if so, what kind of limits does that put around what I should be writing about? It may not sound like much of a conundrum to you, but honestly I have wrestled with this question for a long time. There is darkness in the world: how much darkness should I explore in my books? (So far, if you ever read any of my historical novels, you’ll see the answer is: quite a lot.)

Maybe I’m taking it all too seriously and murder is mere light entertainment now. Death is to be enjoyed with a nice cup of tea; evil, with slice of Victoria sponge cake.

But somehow, I don’t think so.

Recently, I was helped in my moral quandary by another crime author, Andrew Klavan. In his book, The Kingdom of Cain, published last month, Klavan explores the question of evil and specifically murder in what he terms a ‘literature of darkness’. It is a fascinating, if unusual, book. His approach is to take three murders that actually happened, and demonstrate how each has influenced a long succession of murder novels (and movies) up to the present day.

Through this exposition, we witness the changing attitudes to murder over the last century and a half and in particular how those changes seem strongly linked to the ebbing tide of Christian faith in the West.

For example, Dostoyevsky’s great novel, Crime and Punishment, was published in 1866. The double-murder, central to the plot, is carried out by a young student named Raskolnikov. He is an intellectual who is seeking to prove that the moral boundary beyond which murder lies is nothing more than a mere concoction, a social construct (or worse, a religious one) which he, being of superior intelligence, can transcend and therefore ignore. The entire novel is the story of how his conscience will not allow him to get away with this. Near the end, he confesses his crime to the young prostitute, Sonya, who responds to his confession in fearful horror:

“What have you done? What have you done to yourself?”

The second question is key.

Dostoyevsky based the plot of his novel on a real axe-murderer, a Frenchman called Pierre François Lacenaire, who went to the guillotine in 1836. Lacenaire became an international sensation when, in court, he aired many of his own pseudo-intellectual justifications for his actions – that the murders he committed were a strike against the injustice of the elites and the iniquitous power structures of the day. Rather than what they appeared to be: a grubby little double murder for the sake of a few francs. Lacenaire set the tune which many still whistle today, I’m sorry to say.

But Dostoyevsky was prophetic. He foresaw long before Nietzsche and others who would follow, that the tide of Christian faith was going out in Western civilization. And so it continued to do through the back end of the twentieth century and into this one.

Before that, the notion that murder is wrong because every human being is made in the image of God was a long-held axiom, going back arguably to the first chapters of Genesis. And in killing the image of God, any image of God, this may therefore be the closest we can come to killing God himself. Seen in that light, murder is sacrilege on an appalling scale.

But there’s the rub. That light has dimmed. The secular philosophies of the nineteenth and twentieth centuries have turned down the dimmer-switch, so that it is no longer axiomatic that humans possess an inherent sacred value. Instead, in varying guises and to varying degrees, the conclusion has been that humans are nothing but self-conscious lumps of meat. We (the state, the law) may ascribe them some value. “We are all equal,” yes - but as George Orwell anticipated, “some are more equal than others.” (Is intersectionality, for example, anything but the manifestation of that prediction?)

Maybe this explains how the horror of murder has diminished from Sonya’s heart-wringing cry, into something more akin to a crossword puzzle. Don’t get me wrong, I love a good Agatha Christie. But her murder mysteries don’t waste much time on the philosophical implications of, say, the local doctor bumping off the parish priest.

And from there, the genre of the murder mystery has split into two strains. On the one hand, we get the psycho-thriller, in which the horror of the act of murder is of less interest than the dark psychological state of mind of the killer themselves. But if that’s too dark, don’t worry. We can do light, too! And so on to cosy crime blockbusters, in which, if a murder was committed, it was because the victim had it coming – so let’s all calm down and have another slice of cake.

There is no space here in which to explore how, as a culture, our collective historical experience may have helped to steer us in this direction, as well as our changing philosophy. But there is no doubt where we have ended up. We see death cults all around us. We see legislation being passed in our Parliament which would have been unthinkable until very recently. We see social justice where before we saw crimes.

Think about how often the arch-crimes of history have been perpetrated on the ground of viewing the “other” as less than human, and certainly less than sacred. Then ask yourself, why should we see any human as more than a lump of meat? At what point does the rubber hit the road? - as surely it will.

What have we done? What have we done to ourselves?

I do wonder where all this goes. And yet, if the spiritual bellwethers are to be believed, perhaps we have reached low tide at long last – certainly it has revealed some pretty ugly creatures lurking at the bottom of the rock pool. Many, myself included, must hope that the tide of faith is truly on the turn. Let’s see. Certainly, if this proves to be the case, it seems to follow that our attitude to murder will change with that on-rushing tide. And so with it, the literature of darkness.

Beyond The Thursday Murder Club, there may yet be other great stories told of murder; they, like Crime & Punishment, will be far truer, and in a paradoxical sense, far more beautiful. After all, at the heart of the gospel, there lies a murder. If God himself can take such a dark event and turn it into light, then, at a far inferior level perhaps, as His image-bearers, so might we.

Which reminds me… back to my draft.

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