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.

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Biology

Comment

Wildness

10 July 2025

5 min read

There’s a sting in the tail if we construct lessons from nature

Don’t be like the bees

Julia Kendal

Juila is a writer and social justice advocate.

A bee keeper hold honeycomb to the light

HiveBoxx on Unsplash.

‘Be like the bees’ we hear not infrequently. These furry hive dwellers have been coopted by many, from socialists to capitalists, to put a point across. One party draws on their social structure as an inspiration, another their worker bee ethic. They are indeed an example to us. And yet at the same time, bee communities do things that we would find reprehensible in fellow humans. Male bees are expelled from the hive when they are no longer considered reproductively useful. The bees we see out and about this summer are often the oldest, sent to do the dangerous foraging work because they are considered the most expendable. This was a jarring discovery for me, reading it in Katherine May’s timely book, Wintering, during the first COVID-19 lockdown. I was one of the millions shielding and being protected by the ways that society shifted to serve the most vulnerable to the virus; bees, I had just learned, would not behave like this. There are some limits, it seems, to the lessons we construct from nature.

For we do love to construct them. Spend a moment on LinkedIn or Substack, and there are a multitude of articles drawing lessons from the world around us and the creatures we share it with.

This impulse is not new; throughout history, people and communities have done this. People’s relationship with nature is not static or homogenous. The wilderness has been variously a place of fear to be avoided, of growing wonder as described by the Romantic Poets, a site of knowledge neglected by those in power but maintained by others, often women and indigenous communities.

What strikes me about the current trend is that it seems to push to an extreme of unquestioning veneration: nature is perfect and our whole teacher. There are posts about perfect harmony we should emulate, or a call to copy an endless adaptability. These are the things that we might long for – but do not seem to be borne out in ecosystems where sea urchins demolish kelp forests, and the climate crisis reveals the limits of species to adjust. We are being called to see what we want (or feel we need) rather than what actually exists in the world around us.

This instinct to carve lessons from creation extends beyond the natural world to the work of human hands. The Japanese art of kintsugi, repairing broken pottery with gold, has become increasingly prevalent as a metaphor for healing; a beautiful idea but one that risks being stripped of its culture, and that has both limitations and dangers. In Sarah Perry’s novel, The Essex Serpent, Cora’s husband Michael masks his abuse by speaking in a romantic metaphor of his intention to break her down and mend her with gold, like the Japanese art in their hallway. But Cora is not a vase; she is woman. Michael’s breaking harms her. She only begins to repair after he is gone; it is messy, some parts seem irrevocably changed. I think of my own losses, and how healing is indeed available, but rarely as straightforward as putting the same pieces back together. To think it is so can hinder our restoration, and miss out on the transformation that may be possible. As the journalist Poorna Bell wrote after her husband’s death by suicide: “I was in some ways sadder, wiser, but also my existence was much bigger, more honest.”

We have a great capacity to learn – and we need it to survive. As writer Andy Crouch put it in his book, Culture Making: “a human baby is the strangest and most wonderful creature this world can offer. No other mammal emerges so helpless from the womb, utterly unable to cope with the opportunity and adversity of nature. Yet no other creature holds such limitless possibility… We are hard-wired for nothing but learning. All we begin with are possibilities.”

This ability to grow and understand and change is essential if we are to navigate the world. And in our encounters with this place, with brokenness and confusion, the instinct to make meaning, to tidy, to be able to point to something and say 'this is how we should be’ is a form of comfort. Maybe even control it. We are grappling with not just how to understand the world, but how to be in it.

If we are always looking for the lesson, we devalue nature by prizing it just for what it can give us.

Creation and creativity have much to teach us – they’re a testament to and the fruit of the imagination of God. But to prize them just for their lessons seems to fall into another form of extraction and to miss out on something else, something that may be a greater gift in this messy world: wonder.

Bees moving from flower to flower are not setting out on their mission with a side hustle of education for the human race. They are being their full bee selves. Nectar is necessary; this is how it is collected. Bees share knowledge about the good plants via a ‘waggle dance’. This is how the colony persists. It is not for my benefit (though it may encourage me to a moment of playfulness).

Writing this on my balcony, I pause when I see dozens of birds circling one thermal; a moving column of gulls and red kites that goes up and up and up. I could strive for a teachable moment (maybe something about co-existence?) but it feels not just unnecessary, but an interruption. In that moment, I was a human being in awe of birds riding the warm air; that feels like something full of beauty in itself. I worry that if we are always looking for the lesson, we devalue nature by prizing it just for what it can give us. And we miss out on the opportunities to marvel at creation itself.

And, in calling each other to be like other creatures, we accidentally dehumanise other people and ourselves. In the face of conflict, polarisation and disconnection, to contend for each other’s humanity feels vital. And to recognise our own humanness is to acknowledge our limitations. There are parts of nature currently beyond our comprehension. Birdsong holds complexity heard by the intended audience but we can only guess at its meaning. There is something to accepting the edges of our own understanding. Sometimes we touch on truths that seem to contradict or be in tension. Perhaps they are layers that we cannot intellectually fit together but that build up a fuller, richer story that resonates in our souls. Glimpsing something of the multifaceted wisdom and wonder of God himself – and that helps us to remember who we are. A particular type of creature: a human.

So, I won’t be a bee. I’ll keep trying to learn to be what I am: a particular human in a bigger community, world and story. Now, I’m off to admire the goldfinches, glinting in the sunshine.

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