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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Economics

23 October 2024

1 min read

Budgeting for discontent

The Chancellor can't please everyone, but is contentment possible?

Paul Valler

Paul Valler is an executive coach and mentor. He is a former chair of the London Institute for Contemporary Christianity.

A woman stands behind a lectern against a blue and red backdrop.

Chancellor Rachel Reeves speaks at a recent event.

HM Treasury.

As the Chancellor Rachel Reeves seeks to raise billions in this Autumn budget, the news media are all over the downsides. Poor pensioners freezing during winter and businesses complaining of the tax burden are political headlines. Tough choices must be made, but we are rarely happy when it comes to money.

Economic discontent is ironically a cultural norm in first world countries. In the west we have become used to what psychologists call the hedonic treadmill – adjusting our expectations to any new benefits and finding ourselves wanting even more, to try to maintain the same level of happiness. It’s a mentality that dooms us to discontent. Socrates said, ‘He who is not contented with what he has, would not be contented with what he would like to have.’

Contentment seems to be a forgotten virtue today, and increasingly elusive in a society striving for happiness through wealth. Yet being content in life is a more valuable form of wealth than money. There is something enormously attractive about a tranquil state of mind and heart. Contentment does not mean passive acquiescence; there is a noble side to being passionately discontented about something that is unjust – especially when we are fighting for others. William Wilberforce demonstrated that with his campaign for the repeal of laws allowing slavery.

Our personal challenge is to be content in ourselves, whatever the circumstances. Oscar Wilde said, ‘True contentment is not having everything, but being satisfied with everything you have.’ Practising paying attention to what we do have and being thankful for it. That attitude of gratitude is a recognised way to lift our mood and strengthen our resilience. But thankfulness doesn’t solve every problem. Warm words may help warm hearts, but they don’t heat cold homes. Although gratitude is proven to improve our wellbeing, it’s not enough to compensate for all the problems of life. Because here’s the deal; life is tough and then you die, and there are many worse things than economic woes.

Pain, grief and loss are all too common, and they can test our resilience beyond what feels like our ability to endure. Chronic physical or mental illness for example; or being permanently disabled. Or the life-sapping effort to parent children with special needs; or caring for a parent/partner with dementia - especially when it goes on and on. Sometimes horrible events happen like violent abuse, or the deep grief of relationship breakdown or bereavement. This level of suffering pushes us to the end of ourselves, to the place where something more than psychological self-help is needed. What is the secret of contentment then?

I don’t envy the Chancellor, and I do not trivialise the very real challenges raised by having to make tough economic choices.

This is where the secular and the Christian worldview are radically different. Secular philosophers call people to show their own self-sufficiency and superior reason when enduring suffering. This can feel principled and stoic, but it lacks empathy and hope. Christianity accepts the reality of our own weakness and insufficiency, recognising that we can’t fix everything ourselves. Instead of trusting in humanity, we choose to trust God both for this life and the life to come. And this trust and hope is linked to a deeper form of contentment, which transcends pure rationality.

Of course, sceptics say this is just psychological comfort from an imaginary friend, and it doesn’t make sense, because surely any good God would not allow us to suffer in the first place. But any realist must acknowledge that a lot of human suffering comes from the damaging exercise of our own free will. Wars and slavery are examples. If God were to override our free will, we would be robbed of the authentic capacity to love, which makes us fully human. The coexistence of free will, suffering and God is a complex issue.

The experience of millions of Christ followers is that trusting God is much more than imaginary comfort. God is real and prayer changes things; the most ordinary, natural and chance experiences can be affected by it. And prayer changes us. In our vulnerability, if we choose to trust God something changes, we begin to relax, things become a bit easier to bear. In fact, the apostle Paul claimed that Christ’s power was perfected in his own weakness.

Contentment is a strange peace that comes from trusting God in the middle of difficult circumstances. One of the great old hymns was written by a man who lost his four daughters in an accident at sea, and also lost all his money in a fire. The refrain says, ‘It is well, it is well with my soul.’ This isn’t denial or delusion, it is the inner sense of quietness that God can give. Only an eternal perspective allows for that kind of contentment.

I don’t envy the Chancellor, and I do not trivialise the very real challenges raised by having to make tough economic choices. Britain is clearly in a place where some stringent fiscal discipline is needed, and that will inevitably cause some hardship and difficulties. But in the face of all the discontent that is so freely shared in the news, there is another way to respond. Instead of complaining about our flawed Government or moaning about our circumstances, we can change our perspective to put our trust in the ultimate Authority. And in doing so can find a peace that the world cannot give. Contentment is a treasure beyond the wealth of nations.