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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Feminism

Leading

23 October 2024

5 min read

Can Kemi really have it all?

For female experiences to mean something, we need to be part of something bigger.

Sian Brookes

Sian Brookes is studying for a Doctorate at Aberdeen University. Her research focuses on developing a theological understanding of old age. She studied English and Theology at Cambridge University.

A woman works at a laptop on a desk surrounded by picture frame.

Kemi Badenoch campaigning.

Kemibadenoch.org.uk

Apparently Kemi Badenoch is unfit for leadership due to a ‘preoccupation’ with her children. Such comments are hardly a surprise. After all, she is both a mother and a woman vying to be in a position of power. Since the beginning of time women have been mothers, but women haven’t always been in positions of power. So it is not surprising that some people have problems adjusting to the change. But it isn’t just Robert Jenrick who finds this adjustment difficult. In my experience, most women find it hard too. Becoming a mother is a beautiful but body-breaking, exhaustion-inducing and identity-questioning process. And that is just in the first few months. Add to that the expectations of also having successful careers as well, and it is no wonder we find it hard.

Kemi Badenoch’s response, naturally and rightly, was to show how capable she is to lead the Tory party alongside her maternal responsibilities, whilst challenging the view that just because she is a woman she is more responsible for her kids than a man with similar age kids would be. But her lack of acknowledgement of the hardship involved in being a mother and having a successful career does leave an awkward silence around what is an ongoing imbalance in many relationships when it comes to holding the fair share of parental, household and professional responsibilities.

This relentless pursuit of the ability of mothers to do everything else as well as being a mother says something about what we expect from women in our society. We need to prove that it is possible to be a woman and do all the things men have traditionally done. Yet sometimes I do wonder if we make it harder for ourselves. Is it our own expectations which make this thing called being a woman much harder than it needs to be?

Perhaps she is valuable not because of what she does or the choices she makes and what that says about the feminist cause, but because her worth lies elsewhere.

I’ve been blessed with the task of raising three boys, but I think about my friends who are raising little girls and the hopes they have for them. The hopes that they will grow to defy the expectations placed on them because they are female; to counter the oppression put upon them by breaking through the ceilings that may be built over them by others, to become whatever they want to be; engineers, consultant doctors, CEOs, even builders or plumbers if they so desire.

At the same time, (if the girls want them), they are expected to build families and loving safe homes. All of the things our mothers hoped for us and their mothers before them hoped for their own daughters.

Yet now, alongside those hopes for domestic fulfilment, so many other expectations have been added. Of course, the obvious solution to this, as Kemi has argued, is for men and women to share the load on both sides – to build the home and work life in a way that benefits both in the partnership. But the fact remains that relatively speedily in the course of historical development, we have come to a position where we are all expecting to have it all, all the time. And especially for our girls – we want them to be strong, powerful, successful, fruitful and productive all at once.

Now, this is not to say that we should revert to a time when only women ran the household and only men inhabited the professional domain. But sometimes perhaps it’s OK for a woman just to be a mum, if that is what she wants. She doesn’t have to also show the world she can be everything else as well. Some would criticise that decision as selling out on the relentless need to fight for equality with men. But not everything a woman does has to demonstrate some ideological end in fighting for equality, as though that is what gives her value as a woman. Perhaps she is valuable not because of what she does or the choices she makes and what that says about the feminist cause, but because her worth lies elsewhere.

Whatever we do, we do it to witness to a love, a truth which goes beyond whatever we can give to the world.

Many of the friends I spoke of earlier who have those little girls chose to have their daughters baptised as babies. This act of infant baptism puts the stake in the ground for the belief that before they could do anything, before they could prove their worth as a female member of society demonstrating all that power, strength, purpose and ability to right all the wrongs of the past, they were loved and valued beyond measure, without condition.

As a girl, and before they grow to be a woman, maybe a mother, and then potentially the leader of a political party, they are a child of a God who values them not because of what they have done or will do, but because they are His child. At the same time, this doesn’t mean we sit back and do nothing – it’s central to the Christian faith to fight injustice and overturn oppressive powers, but this is never achieved by human action alone as though the weight of the world falls on our shoulders, it is done by bearing witness to a God who has a better plan for the world and for society than we could ever dream or imagine. It is only when we realise this that the burden might be lifted from all the women fighting for all the things we are supposed to fight for.

Of my three closest friends in the church, one is (currently) a stay-at-home mum, one a doctor, one a vicar. As for myself, I am studying for a PhD in theology. We also all spend a lot of time looking after children, cooking and doing the dishes (as do our husbands). And yet, when we reflect together, these choices feel less statements of how we might be empowered or not as women, but more the result of a belief that whatever we do, we do it to witness to a love, a truth which goes beyond whatever we can give to the world. And so, we can each celebrate what we “do” because in each offering of ours can be found meaning, purpose and life beyond our own abilities, even our own individual actions. Perhaps, this is better than any kind of feminism you find around these days, because it allows us each to do the small thing in front of us without loading more on ourselves than we can bear alone. Only together, and only in knowing we are part of something bigger than ourselves, can our variety of female experiences mean something. In this way of living, being a woman feels very free indeed.