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.

Molly Worthen on the charismatic leaders of America's cosmic drama

The plots and plotters that hold us spellbound

Nick Jones

Nick is the senior editor of Seen & Unseen.

Viewed from behind, Trump raises a fist.

Trump on the stump.

White House via Wikimedia Commons.

What happens when Americans lose faith in their religious institutions—and politicians fill the void? In Spellbound: How Charisma Shaped American History from the Puritans to Donald Trump, Molly Worthen sweeping history helps us understand the forces that create leaders and hold their followers captive.

Everyone feels it. Cultural and political life in America has become unrecognizable and strange. Firebrands and would-be sages have taken the place of reasonable and responsible leaders. Nuanced debates have given way to the smug confidence of yard signs. Worthen asks just how did we get here?

Worthen, a historian argues that we will understand the present moment if we learn the story of charisma in America. From the Puritans and Andrew Jackson to Black nationalists and Donald Trump, the saga of American charisma stars figures who possess a dangerous and alluring power to move crowds. They invite followers into a cosmic drama that fulfils hopes and rectifies grievances—and these charismatic leaders insist that they alone plot the way.

Author and historian Tom Holland loved this book.

“The great story of charisma in American history, from the Massachusetts Bay Colony to MAGA, has never been more thrillingly told, never more learnedly explicated.”

In this extract, entitled Plotlines, Worthen introduces her four categories of charismatic leader: Prophets. Conquerors, Agitators, and Gurus.

Plotlines

Over the past several years, whenever I told friends or family that I was writing a book about charisma, they responded with a reasonable question. Which charismatic figures would I include? They peppered me with suggestions: What about Elvis Presley, or Dolly Parton? Michael Jordan or Muhammad Ali? Surely I had to say something about Taylor Swift, right?

None of these fascinating people appears in this book. As you read it, you will probably think of a dozen others whom you wish I had included, and I’m sure you’ll have a point. I have mostly stuck to individuals who worked to build a movement in organized religion or politics, rather than musicians, artists, or athletes. Even within the spheres of religion and politics, I’ve been selective in order to craft a manageable story and bring into focus the patterns and transformations of charismatic leadership over the course of American history.

Sometimes this is an inspiring story, because charismatic leaders often turn up—and people decide to follow—out of a desperate response to alienation and injustice. People in anguish seek a savior. Yet charisma has no fixed moral standing. It can carve a path to freedom or to enslavement; it can lead people to embrace the rule of law or to sneer at it. Charisma causes problems for democracy as well as for authoritarian regimes. Without a sustained analysis of charisma over the long haul of American history since European settlement began, we are doomed to bumble along, blandly observing that ordinary people declare many allegiances that seem to contradict their own material interests and sabotage democracy—but never understanding why.

Over the past four centuries, five types of charismatic leaders have surged to dominance, each offering a variation on the great paradox, a different way for followers to hand over control while feeling liberated. I use these categories both to classify leaders and their movements, and to chart historical change: each type reacts to the type that came before, and responds to the pressures and anxieties of its own era. Like all typologies, this one maps imperfectly onto real people. Almost no one is a “pure” example of these categories, and some leaders are interesting precisely because they react against their age’s dominant type. But these categories have compelled even leaders who defied easy labels—that’s most of them—to respond to the ascendant charismatic style of their age.

The Prophets take us from the end of the Middle Ages into something beginning to resemble our own world. They drew on ancient patterns of contact with the divine to challenge authorities and captivate followers with the terror and ecstasy of God’s presence. They hewed close to tradition, operating in a time when Old World strictures still constrained life in the New World rather tightly. But some used those traditions to undermine reigning institutions, whether by violent rebellion or illicit gatherings—and so provoked a backlash. If the Prophets conceived of freedom in terms of divine salvation, they often harnessed mystical power for this-worldly ends. Usually this meant dismantling any structure that stood in God’s way.

The Prophets were, essentially, destroyers. In their wake they provoked an age of builders.

The Conquerors rose to prominence in the early nineteenth century—an age of mythology, mass media, and frontier enthusiasm in the European American imagination. They swung away from the age of the Prophets, who had so much to say about how powerless humans are.

Some of the Conquerors wielded military power, but all of them pursued what we might call metaphysical conquest. They fought to control spiritual forces. As the predestinarian Puritanism of earlier generations lost its appeal, more people placed an almost fundamentalist faith in the power of free will. It was tempting to think of spiritual forces—perhaps even the Holy Spirit— as a kind of technology, ready for manipulation. The stakes in these campaigns were high at a time when new advances in science impinged on everyday life. Waves of immigration made the country more religiously and ethnically diverse. Americans felt both freer and yet more confined than ever before.

The Agitators gained sway at the turn of the twentieth century, protesting modernity as a raw deal and democracy as tyranny in disguise. The Conquerors had, overall, expanded government authority over Americans’ lives and advanced a golden idea of progress. Now the pendulum swung back toward calls for destruction. The Agitators found a market for attacking the state and denouncing so-called progress as a lie. They defined themselves as outsiders whether they were or not, and discovered that gaining material power does not mean that one must stop telling a story of exile and affliction. This proved to be an important lesson in an age of world war and economic disaster: global crises have a way of transfiguring an outcast dissenter into a credible threat tot he standing order. Meanwhile, Christians grew wilder in their displays of New Testament charisma—because, paradoxically, it was easier to grapple with what Max Weber called the “iron cage” of modernity by embracing ever more outlandish signs of divine power.

The Experts were, on the face of things, the Agitators’ opposite in charismatic style. They were builders. In the wake of World War II, they capitalized on a backlash against the nightmare years of fascist demagogues, embraced the zenith of traditional institutions’ authority across Western culture and politics, and nurtured Americans’ faith in the power of technology and bureaucracy to solve large-scale problems.

They claimed the mantle of reason and procedure and did their best to relegate the political or religious clout of charisma to the distant past or primitive cultures.

But in fact, the three decades after World War II witnessed an explosion of religious revival in America—led by Christians who spoke in tongues, looked for the end times, and claimed to heal through the power of the Spirit. Even in the domain of credentialed and supposedly secular healing, the line between medicine and spirituality grew fuzzier. These years were the Experts’ apogee of cultural prestige, but Americans’ long- standing ambivalence about intellectual elites persisted. The most successful leaders capitalized on those mixed feelings. They nursed the tension between the Cold War celebration of science and freedom and, on the other hand, the lurking sense that technological leaps obscured eternal truths and needed the organizing power of a good story.

By the end of the twentieth century, as Americans lost faith in established media, churches, government, and nearly every other bulwark of modern society, the destructive strain of charismatic leadership re-surfaced in the form of the Gurus: preachers of self-actualization and get-enlightened-quick schemes, promoting God’s new temp job as personal assistant. Old-fashioned Pentecostal revival persisted too, but its leaders struggled to prevent the culture wars from capturing the Holy Spirit.

The Gurus looked, at first glance, like the Prophets and the Agitators. But in the generations since those earlier eras, it had become harder to pay obeisance to tradition—which was just fine, since the erosion of institutions had weakened traditions anyway, and opened a path for Gurus to achieve more influence than their destructive predecessors. Religious and philosophical tradition, in the hands of the Gurus, was no longer a firm guide but a palette for painting illusions of independence. Sometimes they used it to depict a new reality impervious to fact-checkers.

“Guru,” which means “remover of darkness” in Sanskrit, was originally a religious term. But in the third decade of the twenty-first century, the most prominent guru in the country was a businessman named Donald Trump. Trump was not, personally, a paragon of conventional religious devotion. Yet his political career depended on a hunger among his most dedicated supporters that can only be called spiritual. Like so many relationships between charismatic leaders and their followers, it stumped and angered those on the outside. Against the backdrop of the American charismatic tradition, however, his success makes perfect sense.

How, then, did early modern mystics and Puritan heretics who heard the voice of the Holy Spirit give way to devotees at a modern presidential rally, jostling toward the candidate iPhone-first, praying for a selfie? By the early twenty-first century, most religious institutions in the West had declined into husks of their former authority—at least by the usual measures. Today commentators turn more than ever to materialist explanations for political dysfunction, polarization, and the culture’s general crisis of confidence. They cite growing social inequality, impassable disagreements on policy, persistent racism and xenophobia, evil automated forces lurking on the internet. All true—yet all insufficient accounts. If we define the religious impulse as a hunger for transcendent meaning and a reflex to worship, then it is a human instinct only slightly less basic than the need for food and shelter, and Americans are no less religious than they have ever been. They will always find a way to satisfy these desires, even if charisma carries them down strange and costly paths.

Spellbound: How Charisma Shaped American History from the Puritans to Donald Trump, Penguin Random House, 2025.