Article
Assisted dying
Comment
Politics
7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

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
Gaza
Israel
Middle East
Old Testament
Trauma
War & peace
10 min read

Two years on: the tragedy and the trauma of Gaza

As the anniversary of 7th October comes round again, an ancient story helps shed a new light on this conflict

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

Split-screen on TC shows many different news channels in English, Arabic and Hebrew.
Split-screen reporting.
Al Jazeera.

It is now two years since Hamas' vicious attack on Israeli citizens at the Nova music festival. Two years later, much of Gaza lies in ruins, nearly 70,000 of its people have died, and Israel continues its campaign to rid itself once and for all of Hamas, a hostile neighbour. The spectre of antisemitism has raised its ugly head again on the streets of Manchester. Meanwhile, the world waits to see if the Trump peace plan has a chance of working. 

The world is also deeply divided on the question of who is to blame here. Is it, as the Israelis say, firmly Hamas’ fault, the result of a fanatical Islamist group, sponsored by Iran, determined to extend militant Muslim control over the Middle East in general and Israel in particular? Or, as the pro-Palestinian crowds chant, are we watching a genocide which is the inevitable outcome of Israel’s ongoing occupation of the West Bank and Gaza? Everyone is pushed to decide. As a child of a friend asked his mum the other day: “Which side are we on?” 

Yet what if we try to see this conflict in a different light - not so much in terms of blame but pain?

Echoes of the past

Of course, this is not the first time there has been war between the people of Israel and their enemies on the coastline of Gaza.

The book of Judges in the Bible recounts a series of confrontations around 3,400 years ago between the Israelites and the Philistines, who harassed and taunted the Hebrew tribes as they struggled to establish themselves in the land of Canaan (NB - the Philistines are not the ethnic ancestors of modern Palestinians, despite the similarity in name. The Romans. partly to annoy the Jews, simply decided to change the name of the region from Judaea to Palestina.)

One of those ancient stories tells of Samson, an immensely strong Israelite warrior, who kills numerous Philistines in a spree of violence lasting several years. Samson eventually marries a Philistine woman, Delilah, who betrays him into the hands of his enemies. He is captured, and his eyes are gouged out. In a final act of violence, he brings down the roof of the Philistine Temple at the height of a religious feast, killing both himself and more of his enemies than he killed in his lifetime.

The story is both a tragedy and a trauma. John Milton’s great verse drama Samson Agonistes, written around 1650, presents Samson as a tragic figure, gifted and heroic, a hero of Israel brought low into his Gazan prison by a fatal character flaw of pride and lust, betrayed by his cunning wife, and in his famous phrase, ‘eyeless in Gaza at the mill with slaves, Himself in bonds under Philistian yoke’. The tragedy ends in his final act of destruction of both himself and his enemies.

Yet besides a tragedy, this is also trauma. The roots of the trauma lie deeply hidden in the history between Israel and the various tribes that surround them. Samson is one of many dragged into a history of tit-for-tat violence which ends in this scene of death and devastation. In the story of the Bible, he is caught up in the long history of human wrongdoing – as both victim and perpetrator - that stretches right back to Adam and Eve in the garden. The result is Samson and his enemies all lying dead in the rubble of a demolished building in the heart of Gaza.

In this one small strip of land today we find two peoples living out the trauma of what has happened to them in the past. And without a new approach, the result will be the same – destruction and devastation.  

On many trips to Israel/Palestine over the past 35 years, as I listened to Palestinians and Israelis look at the same issue with such different eyes, this conflict often struck me as both a tragedy and a trauma. That sounds bleak. Yet this perspective can, despite its apparent gloom, bring a glimmer of hope.

Tragedy and trauma don’t avoid the question of blame, but they don’t start there. They start with a posture of empathy. Tragedy makes us pause before making moral judgments and instead, simply to notice and enter into the sadness, the grief of it all. When we watch the final scenes of Hamlet or Macbeth, or even the Samson story, we are simply left in silence. We don’t rush to judgment, but simply acknowledge the heart-breaking sorrow experienced by the ordinary people caught up in this. Tragedy sits with the grief and darkness, and does not reach immediately to blame, realising that real life is usually more complex and the causes of conflict more opaque.

At the same time, understanding this as trauma forces us to enter into the pain underlying the conflict. Samson is born into traumatic times with his people under attack, and ends up living out the trauma he has experienced by brutal revenge on his enemies. In a similar way, in this one small strip of land today we find two peoples living out the trauma of what has happened to them in the past. And without a new approach, the result will be the same – destruction and devastation. 

The Jewish people of today, especially in Israel, remain deeply traumatised by the history of anti-Semitism which climaxed in the Holocaust of the 1930s and 40s. A determined attempt by a sophisticated, modern European nation to systematically exterminate every single one of the Jewish race is not just a historical event but one whose ripples or perhaps better, stormy waves, reach us today. Alongside this there is the expulsion of Jews during the C20th from Muslim countries such as Syria, Iraq, Yemen, Algeria, Tunisia and Libya. For those of us who are not Jewish it is hard to imagine the impact of such a reality, not just as a fact of history but as a real danger in the future. After all, if it happened once, it could happen again. It explains why Israel has always paid scant attention to international opinion and resolutions of the UN for a ceasefire, such as the one recently called for. As the Jewish writer Daniel Finkelstein put it:

“The origin of the state of Israel is not religion or nationalism, it is the experience of oppression and murder, the fear of total annihilation and the bitter conclusion that world opinion could not be relied upon to protect the Jews. So, when Israel is urged to respect world opinion and put its faith in the international community the point is rather being missed. The very idea of Israel is a rejection of this option. Israel only exists because Jews do not feel safe as the wards of world opinion. Zionism, that word that is so abused, so reviled, is founded on a determination that, at the end of the day, somehow the Jews will defend themselves and their fellow Jews from destruction. If world opinion was enough, there would be no Israel.”

So, with such a trauma behind them, it is not surprising that when a Muslim kills Jews in a British synagogue, when rockets rain down on Israeli towns, or Hamas militants swagger through kibbutzim, shooting people just because they are Jews, it triggers exactly the memory of the trauma that they have been through as a people. What Palestinians think of as resistance to an occupation of their land, is experienced by Israelis as an echo of the desire to exterminate the entire Jewish people, in a way that sends a shiver down the spine for anyone who has lived this story.

Just like Samson and his enemies. An eye for an eye leads both to end up eyeless in Gaza.

Yet the Palestinian people also have a trauma of their own. In 1948, at the time of the creation of the State of Israel, hundreds of thousands of Palestinians were made homeless and stateless, deprived of their homes and their land, often at gunpoint, and many killed by Zionist fighters. The Arab nations did little to help, only interested in their own interests. The European nations stood by. America continue to fund Israel so that their army vastly outweighs any other army in the region, and certainly enough to crush the stones, knives and bombs of various intifadas. Their deep sense of injustice also leaves a scar, one that can continue to be used by groups like Hamas for their own purposes.

And so today when Gazans watch their cities pummelled to dust, when Palestinians are made to queue at checkpoints simply to travel from one place to another,  when land is taken through the building of a security wall, and Israeli settlements continue to get permits to build on Arab land, while it is much harder for Palestinians to get planning permission to build a new home, all this triggers the memory of what Palestinians call the Nakhba or the disaster. What Israelis see as legitimate self-defence, security measures to keep terrorists at bay and to keep their people safe, is experienced by Palestinians as an echo of their own past trauma of dispossession.

The result is that both sides end up caught yet again in a cycle of violence, just like Samson and his enemies. An eye for an eye leads both to end up eyeless in Gaza.

Yet this approach perhaps places upon us who look on, the responsibility to try to enter into the pain of the other side.

Now of course, we can argue about which trauma is the greater. We can debate the merits of each moral case, or where real blame lies. But trauma doesn't work like that. Trauma sits within the mind and the body, and spreads, overwhelming any ability to cope normally and react with a sense of proportion and balance. The effects of trauma are not deliberate or logical but involuntary. Reactions to trauma are notoriously complex and differ according to individuals. Trauma stays with individuals for years and with communities for generations.

Understanding this conflict not so much as through the lens of blame but of pain may help us understand this conflict differently. Of course, it doesn't avoid the question of blame, because terrible things have been done here. It also doesn’t deny Israel’s right to defend itself against Hamas’s attack with legitimate force. Most of us tend to lean towards one side or the other of the conflict. Yet this approach perhaps places upon us who look on, the responsibility to try to enter into the pain of the other side. And when the dust of battle settles, it perhaps promises a better way to cut the cycle of violence in the future.

Understanding this conflict as both tragedy and trauma helps us see it in a new light. And perhaps it gives us the glimmer of a hope of a way forward. The memory never goes away, but trauma victims can find ways to approach the memory of what happened to them in different ways.

The story of Samson ends with destruction and his burial in the family tomb. It ends in death. Within the long story of the Bible, however, the chaotic period of the Judges is superseded by the monarchy – the kings of Israel, the best of whom is King David – a ruler with flaws, but described as ‘a man after God’s own heart’. Beyond that, the story of David points to a later ruler also born in Bethlehem, whose rule meant not hating and killing his enemies, but loving them to the point of dying for them, thus, finally, bringing peace. It is that kind of Jesus-shaped, self-sacrificial, radical, counterintuitive leadership on both sides that can show a way out of the cycle of violence and hatred that was there in the period of Samson, and is there today.

Only leaders who are not concerned with doing whatever it takes to stay in power, nor willing to sacrifice others for their own purposes, who don’t care about personal reputation, but are willing to take the risky path of reconciliation, as I have argued elsewhere on Seen and Unseen - only this kind of leadership can lead us beyond the tragedy and trauma of the past into a more hopeful future.

The last word might come from Audeh Rantisi, a Palestinian evicted from his home in Lydda in 1948. He went on to become an Anglican priest and an activist for reconciliation between Jews and Arabs and the need for both to recognise the scars and humanity of the other:

I still bear the emotional scars of the Zionist invasion. Yet, as an adult, I see what I did not fully understand then: that the Jews are also human beings, themselves driven by fear, victims of history's worst outrages, rabidly, sometimes almost mindlessly searching for security.

Four years after our flight from Lydda I dedicated my life to the service of Jesus Christ. Like me and my fellow refugees, Jesus had lived in adverse circumstances, often with only a stone for a pillow. As with his fellow Jews two thousand years ago and the Palestinians today, an outside power controlled his homeland - my homeland. They tortured and killed him in Jerusalem, only ten miles from Ramallah, and my new home. He was the victim of terrible indignities. Nevertheless, Jesus prayed on behalf of those who engineered his death, "Father, forgive them..."

Can I do less?

 

This article is an updated version of one first published on 7 November 2023