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. 

Essay
Culture
Film & TV
Monsters
Politics
13 min read

In an age of nihilism it's time to revisit The Dark Knight

Batman, the Joker, and the disaffected

J.W. is a lecturer in the Study of Religions at the University of Oxford.

The Joker and Batman sit opposite each other in an interrogation room.
Warner Bros.

Christopher Nolan’s groundbreaking film The Dark Knight (2008), the second installment of his Batman trilogy, was a summer blockbuster that changed the superhero genre forever. Nolan’s gritty, realistic depiction of the Caped Crusader, played by a stoical Christian Bale, pushed back against the then nascent resurgence of comic-book cinema. Nolan resisted flashy computer-generated fight scenes and digitized superpowers in favor of psychological thrills intensified by cinematic restraint. The film’s combined financial and critical success empowered Nolan to become the preeminent big-budget auteur of Hollywood, going on to make such mind-benders as Inception (2010) and Interstellar (2014) and resurrecting the summer movie-going craze with the psychological biopic Oppenheimer (2023).  

The Dark Knight changed the way the superhero genre was perceived not only because of its realism and cinematic skill, but also—perhaps principally—because of the late Heath Ledger’s performance as the Joker, Batman’s premier antagonist and the main villain of the film. Ledger’s Joker was mythologized even before the film’s release, as the actor’s untimely death from a drug overdose in January 2008 was almost immediately credited by the media to the intensity of having inhabited the Joker’s personality. Of more lasting importance, Ledger’s Joker in many ways marked the first serious consideration of moral and political nihilism for a large audience. The villain put on the page by Nolan and brought to life by Ledger (in a posthumously Academy Award-winning performance) was at turns disturbing in its philosophical coherence and alluring in the authenticity with which the Joker lived his principles. Batman was the unambiguous “good guy,” but the Joker captivated the audience’s imagination. I can remember being a high schooler the year after the film’s release, and at every sporting event or dance party there were dozens of Joker faces in the crowd, with the signature white makeup and lipsticked smile. Never before had insanity been so attractive. For those of us raised in the suburban optimism of the 1990s, this was the first time that nihilism had become cool. 

In the wake of recent surges in political nihilism, though, ranging from online incel culture to a flurry of successful and attempted political assassinations to the January 6 capitol riots, it is perhaps worth revisiting the ideas considered by The Dark Knight nearly two decades after its release. Ours is a disaffected age, marked by despair at institutional incompetence and corruption on the one hand and a desire for a radical overhaul of justice on the other. As is often remarked, the predominant demographic of contemporary performative nihilism is millennial and Gen Z men, many of whom would have been old enough to see The Dark Knight in theaters but young enough to be profoundly impressionable to its ideas. It is not unreasonable to believe that the film acted as a foundational, if perhaps unconscious, philosophical education for whole generations coming of age in a cynical environment. Revisiting The Dark Knight today thus offers a potential lens on the sociopolitical challenges we face and the available philosophical and theological responses to them. 

Part of the Joker’s appeal comes from the audience’s upfront endorsement of extrajudicial justice. No one enjoys a superhero flick unless they are willing to suspend the state’s monopoly on righteous violence, at least for the duration of the film. The romance of the genre comes from getting to vicariously live the hero’s superseding of the limits of legality, which is legitimated by their superior sense of justice. We are meant to envy Batman’s vigilantism: even when the authorities come after him, he is always too crafty, too physically fit, and too technologically advanced for the bumbling police to handle. This contempt for the law is then assuaged for us by a vision of justice that actually effects the change for which we long. The vigilante movie depends on ends that clearly justify the means. 

Philosophical Joker 

Released in the summer of 2008, The Dark Knight would have spoken to a generation of youth raised on the cynicism of post-9/11 society and distrust of authority resulting from the interminable war in Iraq. Even as the film was entering theaters, the global financial crash was well underway, even if the majority of the public was as yet unaware of it, spurred on by government deregulation in favor of too-big-to-fail banks and their dubious financial exploitation of the middle class. The resulting economic downturn, amplified for millennials by ballooning student loan debt and the ineffectiveness of university degrees as a stepping-stone to quality employment, would in turn have elevated Batman’s appeal in the years after the film’s release. Unlike other superheroes whose power resides in abilities we can never possess, Batman’s fully human limitations and resourcefulness uniquely channel our anger into seemingly plausible solutions. (The film seems to recognize this, as a theme early on in the movie is Batman’s struggle to control less skilled copycats of his vigilante style.) Batman sanitizes our thirst for vengeance under the aegis of a higher justice.   

The effectiveness of the Joker as a philosophical villain, then, comes from the incisiveness with which he accurately diagnoses the inconsistencies in Batman’s arrangement with the law. In an early scene, the Joker attempts to make inroads with the mobsters of Gotham City. When their accountant flees to Hong Kong because it is beyond the jurisdiction of district attorney Harvey Dent, the Joker responds, “Batman has no jurisdiction. He’ll find him and make him squeal.” That Batman then predictably follows through on the Joker’s prediction—kidnapping the accountant with some spectacular escape artistry—is apparently no cause for the audience to question whether the Joker might be onto something.  

The Joker’s philosophy in many ways articulates Batman’s actions better than Batman’s own worldview. Batman wants to inspire the public to justice. But what he is in fact doing is undermining the legitimacy of the institutions charged with enforcing justice, implicitly endorsing anarchism as a necessary response to official corruption. Of course, the Joker doesn’t malign Batman for his contempt of corruption but only for his hypocrisy. In what amounts to his philosophical manifesto, toward the end of the film the Joker explains his worldview to a newly scarred and traumatized Dent, attempting to lure him into his orbit: 

They’re schemers. Schemers trying to control their little worlds. I’m not a schemer. I try to show the schemers how pathetic they’re attempts to control things really are… It’s the schemers that put you where you are. You were a schemer. You had plans. And look where that got you…  

You know what I’ve noticed? Nobody panics when things go ‘according to plan.’ Even if the plan is horrifying. If tomorrow I tell the press that, like, a gang-banger will get shot or a truckload of soldiers will be blown up, nobody panics. Because it’s all ‘part of the plan.’ But when I say that one little, old mayor will die, then everyone loses their minds! Introduce a little anarchy. Upset the established order, and everything becomes chaos. I’m an agent of chaos. Oh, and you know the thing about chaos? It’s fear. 

The Joker’s worldview, in a nutshell, is that evil is baked into the state’s attempts at control. No matter how hard they try, official authorities (governments, police, even churches) will never be able to enact real justice but only a mediocre shade of it. The compensation they provide is little more than a narrative to justify our collective misery and, if we’re lucky, a series of spectacles to distract us from our malaise.  

Ahead of the curve 

The Joker is in many ways a firm believer in existential freedom. Despite his apparent flippancy, he is the most serious character in the film, completely committed to his philosophy. The laughter and joy with which he carries out his heinous crimes is as much evidence of the ecstasies of genuine freedom as it is an indication of psychological disturbance. Contrary to the views of some, the Joker of Nolan and Ledger is not mentally ill. He is completely rational. He knows the human capacity for transcendence and finds civilization wanting as a vehicle for true human flourishing. He recognizes that we all know this to some extent, and he further recognizes that our primary motivation for denying our freedom is fear and convenience.  

During what is probably the film’s philosophical climax, Batman conducts an extrajudicial interrogation of the Joker. In a profound twist, it is the Joker who is the more rational of the two characters in this scene, accurately diagnosing the unacknowledged dark side of Batman’s ideology while the ostensibly self-disciplined hero spirals into ever more erratic violence. Derisively comparing Batman to official law enforcement, often maligned throughout the film as variously corrupt or incompetent, the Joker says:  

Don’t talk like one of them—you’re not, even if you’d like to be. To them you’re just a freak. Like me. They need you right now. But when they don’t, they’ll cast you out like a leper. See, their morals, their code: it’s a bad joke. Dropped at the first sign of trouble. They’re only as good as the world allows them to be. I’ll show you. When the chips are down, these ‘civilized’ people, they’ll eat each other. See, I’m not a monster. I’m just ahead of the curve. 

In one fell swoop, the Joker has indicted both Batman and the establishment. If we side with the government, then we accept hypocrisy and ineffectiveness as the cost of a milquetoast justice. A grown adult fighting crime in a mask is freakish and absurd, nothing more than fantastical escapism. It is better to fall in line and get over your ideals. But if we instead take the side of Batman, then we have already cleared the greatest hurdle to embracing the Joker’s monstrosity. 

The righteous Batman 

Batman’s justice is derived from his single principle not to kill. He is constrained by neither ideological mercy nor legal precedent but only his own conscience. Yet as the Joker points out, once a vigilante has decided that their own justice is sufficient to discard the law, there is little to stop them from forsaking rules altogether: “The only sensible way to live in this world is without rules. And tonight you’re gonna break your one rule.” Batman understandably becomes more violent as the dialogue continues, exposing the dark side of his extralegal sense of justice. Pummeling the Joker in the interrogation room, Batman becomes a villain in his own right, enacting the Joker’s plan to perfection. The Joker wants Batman to kill him, if only because then the Joker’s triumph will be complete. One thinks here of Obi-Wan’s statement to Darth Vader in Star Wars (1977): “If you strike me down, I shall become more powerful than you can possibly imagine.” Or the final scene in V for Vendetta (2005): “Behind this mask there is an idea. And ideas are bulletproof.” The Joker’s philosophy is not proved by the superiority of his own strength but by his ability to lure even the most righteous figures into the abyss. Once stated, his diagnosis becomes a self-fulfilling prophecy. In his own words at the film’s finale, “Madness, as you know, is like gravity. All it takes is a little push.” From the first time he donned the mask, Batman had entered the realm of nihilism. The Joker is simply pointing this out and trying to get him to follow through to vigilantism’s natural conclusion.  

In his ideological war with Batman, the Joker’s final trick is consequently to turn Gotham City into a madhouse. If the general public caves to fear and begins to tear itself apart, then the Joker’s assessment of human nature will be proved correct. In the film, Batman is justified, first by the civilians and prisoners who collectively choose not to blow up each other’s boats with the Joker’s explosives (perhaps more out of cowardice than idealism) and then by his decision to personally take the blame for Harvey Dent’s murderous rampage in order to preserve Dent’s inspiring figure for the public. Whether or not these constitute real victories is debatable, but the film ends by willing us to believe that Batman’s worldview is not inconceivable for average folks like us. In an obviously Christlike swap, Batman is so righteous that he is even willing to take the consequences of the corrupted sinner on himself in order to redeem both the sinner and the public who needs him as their hero. 

But with the contemporary proliferation of illiberal ideology, the dissemination of myriad conspiracy theories, and the surge in political violence in the years since The Dark Knight’s release, we may have cause to reassess the outcome of this ideological battle. Has Batman or the Joker more accurately grasped the modern public’s psyche? Is it the Joker or the film’s optimistic finale that is spinning a fantasy?  

Jesus and The Joker 

From the Christian perspective, the question is nuanced but not necessarily answered. The Jesus of the gospels is by turns vigilantist, nihilistic, and neither. He is at some moments indifferent to the state—as when he endorses paying taxes to Caesar while unambiguously discounting money as having any real value—and at other times openly hostile, as when he challenges King Herod as a schemer in the mode of the Joker’s own critique. He self-consciously transcends the law without abolishing it. The entire Sermon on the Mount endorses a view of justice that goes beyond what could ever be meted out by law or reasonably enforced by institutions. Jesus is even willing to engage in some raging guerilla theatre to expose corrupt institutional authorities, and he frequently lambasts legalist hypocrites for preaching an ideology inconsistent with their practice. 

If I had to stake my own interpretation, I would aver that the Jesus portrayed in the New Testament is closer to the Joker’s nihilism than to Batman’s vigilantism, both in his own behavior and the model he endorses for others. Of course, Jesus’ pacifism differs immensely from the murderous Joker. The Joker wants to make a point through the expense of human life. For Jesus, abundant human life is itself the point. Jesus forgives his persecutors from the cross and condemns violence as a response to injustice. But what Jesus and the Joker both fundamentally agree upon is the inadequacy of institutional channels for true justice. Batman might agree in principle, but his view of justice is plagued by internal contradictions: He abandons the law while seeking to uphold it; he forsakes legal constraint while encoding justice in specific principles.  

What the Joker gets right from the Christian perspective, even if he never says so, is that genuine flourishing is incompatible with legal framing. Spontaneity, play, and delight are essential to human freedom. The Joker exemplifies this, even if his joy is perversely tethered to violence. What the Joker desires is evil, but he effectively illustrates how law devoid of desire cannot amount to justice.  

For Jesus, true justice consistently comes down to love, which is nothing if not rooted in desire. The only motivation to turn the other cheek, pray for your enemies, or give all your possessions to the poor is because you truly desire to do so. Such extreme acts of charity are absurd by the standards of the social contract. Transcending social and legal expectations can have no motivation other than desire. Gratuity, in the sense of both an unmerited gift and ridiculous excess, is the defining feature of Jesus’ ethic. This comes through most profoundly in Jesus’ metaphors for the Kingdom of God: a weed that grows like crazy, a pound of yeast in fifty pounds of flour, an economy where everyone gets paid the same regardless of merit. We need to remember that Jesus attracted the kind of followers who walked off good-paying jobs and abandoned their boats on a whim. The Joker has just the right amount of insanity to be a Christian, even if he misses the key ingredient of love.  

This sketch of a classic film and the character of Jesus is not enough to provide a coherent ethical program. But that is precisely not the point. The attempt to narrowly codify justice is what Jesus and the Joker both call out for hypocrisy, and it’s the thing that sends Batman spiraling through contradictions. If we are to properly respond to the nihilism that surrounds us online and in our politics today, then we first need to appreciate the credibility of the nihilistic diagnosis of contemporary life. This does not mean conceding to the despair that leads to hatred and violence. If anything, the life and teachings of Jesus illustrate something akin to a post-nihilistic doctrine of love. Just as resurrection requires death, so answering nihilism might require passing through it rather than ignoring its existence. Like Batman, Jesus insists that true justice is realizable for all of us. Like the Joker, though, Jesus understands that this requires a leap into the absurd. We cannot love until we can play, when we burst the bounds of cultural norms and the status quo. We will be truly just only when we find the freedom to go beyond what is required and chart a new frontier, when we learn to jump out of the boat and wager our sanity on the absurd.  

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