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.

Nigeria’s terror survivors share their stories

This violence is not gruesome fiction, it’s reality.

Belle Tindall

Belle is the staff writer at Seen & Unseen and co-host of its Re-enchanting podcast.

A Nigerian man looks up towards the camera, behind him is dusty ground

Manga survived an attempted beheading.

Open Doors.

This article contains distressing content.

Something is happening. And nobody is talking about it.

Nigeria, the big and beautiful ‘Giant of Africa’, is becoming a place of increasing terror for the hundred million Christians who call it home. Since 2000, 62,000 people have been killed for having a Christian faith. Eight-thousand people were killed in 2023 alone. These staggering numbers mean that more Christians are being killed in Nigeria than in every other country combined.

The violence is as extreme as it gets. And yet, very few of us know that it’s happening.

When it comes to the Nigerian government and media, the relentlessly brutal attacks are seemingly hidden in plain sight; undeniable and yet somehow unstoppable. While, in the UK, we appear to be entirely unaware. This violence is out of sight, and therefore largely out of mind. The reasons why are admittedly complex, as outlined by Chris Wadibia. Nevertheless, the violence being carried out toward the Nigerian people, particularly those living in the Northern states, surely deserves our attention.

Earlier this year, I took a trip to Northern Nigeria. While I was there, I got to know a group of people who had endured unimaginable trauma, largely because of their Christian faith. Every day, they would bravely tell their stories – who they were and what they had experienced. Every day, I looked into the faces of children who had lost parents, parents who had lost children, husbands who had lost wives, and wives who had lost husbands. All of a sudden, the bewildering statistics were people before me – people who were having to live with the images of their loved ones being ‘butchered’ before their very eyes. Their villages being burnt down. Their lives being turned upside down by militants with assault rifles and machetes.

The only reference I had for stories such as the ones I was hearing were apocalyptic movies. But these things happened. They happened to the people sitting across from me. This violence is not the stuff of gruesome fiction, it’s the stuff of reality.

As she was running, she came across a woman who has hiding herself because she was giving birth to twins. This mother handed the babies to her and begged her to get them to safety...

I met one woman, she was incredibly gentle and kind, and told her story with a composure that’s hard to fathom. She was working on her land along with her husband and mother-in-law, a totally run-of-the-mill day. They were so engrossed with the task at hand, they didn’t notice that their village was being attacked by armed ‘Fulani’ militants (the majority of the violence being carried out in Northern Nigeria is at the hands of Islamic extremist groups such as Fulani militants, Boko Haram and ISWAP - Islamic State in West African Province). She looked up to find herself face-to-face with two attackers and despite their command for her to surrender to them, she ran, as did her husband and mother-in-law. While she was running, she could hear bullets flying past her head and the screams of her mother-in-law. Making it to a neighbouring village, she gathered help and eventually went back to find her husband and mother-in-law. Both of whom were stabbed and killed that day.

The Fulani militants now have control over her village, and she told us how she’s been praying that she would be able to forgive these men for what they’d done, as she is now forced to live alongside them. And so, she felt proud because she had recently been able to respond to one of the men as they greeted her.

There was another woman, she was strong and defiantly compassionate. Her story is laced with horror. She studied at a university – the discrimination she experienced there meant that a course that was supposed to be four years long, took her eight years to complete. In 2014, Boko Haram attacked the university – while she was trying to escape, her friend was shot and ‘hacked at’ while he refused to deny his Christian faith. She recalls how his last words were ‘I’m happy. I’ve saved lives today. And I have Jesus’.

He died and she continued to run. As she was running, she came across a woman who has hiding herself because she was giving birth to twins. This mother handed the babies to her and begged her to get them to safety, as she did so, she heard the mother being shot behind her.

She ran those twins to Cameroon, leaving them in safety, and now lives in a rural Nigerian village where she teaches the local children. Her Christian identity is no secret, and so faces continual danger. Her crops were burnt to the ground and destroyed, twice. And the villagers have tried, repeatedly, to get her to leave. One night, she came face to face with young men with bats and machetes who threatened her life – she told them – ‘you can’t scare me. I have seen the Lord’.

And they left. Remarkably, that village is still her home.

One heart-wrenchingly-young girl told us how, while she sleeping – she was awoken by her father who told her that they needed to run, they were under attack. She ran, hand in hand with her father, while her mother carried her younger brother. While they were fleeing, her dad was shot and killed. Her mother pried her hand out of her father’s and buried both her and her brother in sand, instructing them to stay hidden. The next day, they found that their house, their crops, their entire village had been burnt down.

This is what is happening. This is what we are not seeing.

While we are not seeing this violence, they are not seeing an end to it.

Since my return, I have met with a man who bears the physical scars of his trauma. He thought his house was being pillaged by armed robbers - it was only when they led him, his brother and his father outside, made them kneel with their hands tied behind their backs, and demanded that they denounce their Christian faith that he realised he was being attacked by Boko Haram. It was a regular evening, he was putting together a lesson plan for his class the following day, and now he was kneeling before an executioner. His father refused their demand, and they beheaded him. His brother also refused, and they took a blade to him, too. Then it was his turn, and while his mind was filled with thoughts of death and how much this was about to hurt, he also prayed that these men would be forgiven for what they were doing. Taking after Jesus, who forgave his executioners mid-execution, this man continued to pray as he felt the blade in his neck.

Left to bleed to death, miraculously, both him and his brother survived. Now, his scar tells an astonishing story.

This epidemic of violence seems to reside under our radar. It’s not quite catching our eye, is it? And, as a result, is not quite receiving the force of our outrage nor benefiting from the depths of our compassion. So many of the people that I met expressed a feeling of being neglected – like they’re suffering in deafening silence. While we are not seeing this violence, they are not seeing an end to it.

What’s happening in Nigeria is a crisis, one that we must acknowledge.