Article

Assisted dying

Comment

Politics

25 November 2024

7 min read

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.

Article

Comment

Mental Health

Poetry

15 October 2024

4 min read

Auden and our anxious age

While the tropes of trauma are still with us, how to not die in our dread?

Jack Nicholson

Jack is a graduate of Peterhouse, University of Cambridge and Blackfriars, University of Oxford. He writes, and also works in local government.

An outdoor vigil is lit by people holding up mobile phone lights.

Oxford's peace vigil.

BBC News.

Faces along the bar

Cling to their average day:

The lights must never go out,

The music must always play . . .

Lest we should see where we are,

Lost in a haunted wood,

Children afraid of the night

Who have never been happy or good.

This week, we mark the 85th birthday of W. H. Auden’s poem ‘September 1st, 1939’. He describes four solitary drinkers in New York on the cusp of the Second World War. September 1st, 1939: Hitler invades Poland. Those four faces struggle to find meaning in their lives.

In a later, much longer poem of 1947 (first UK edition, 1948) Auden built on this theme, having lived through the War, to identify an ‘Age of Anxiety’. He wrote, ‘We would rather be ruined than changed / We would rather die in our dread / Than climb the cross of the moment / And let our illusions die.’

I have been reflecting on this of late, especially in light of a recent night vigil for peace, remembrance, and unity at Bonn Square, Oxford, where I live. This took place on 7 October, the anniversary of the Hamas attack on Israel in 2023: the darkest day in Jewish history since the time that Auden wrote his poems.

In an Age of Anxiety, Auden wrote, ‘the world needs a wash, and a week off’. The gathering in Oxford was especially poignant because some 250 people chose to go out in the rain, on their Sunday-evening time off, and in the darkness, to hear prayers and readings from different communities. It was as if the world was awash with people coming together.

The Bishop of Oxford the Rt Rev’d Dr Steven Croft said, ‘Our purpose is simply to be together.’ People simply had to do ‘something in the face of the helplessness that we all feel, in the face of these terrible events’. Louise Gordon, co vice president of the Oxford Jewish Congregation, described people ‘clinging to hope’. Imam Monawar Husain stressed that togetherness as such is a ‘symbol’, a symbol of hope.

Symbols abounded. Candles were lit. In ‘September 1st, 1939’, Auden described ‘Ironic points of light’ which

Flash out wherever the Just

Exchange their messages:

May I, composed like them

Of Eros and of dust,

Beleaguered by the same

Negation and despair,

Show an affirming flame.

The crowd spontaneously joined in with the protest song ‘Where Have All the Flowers Gone’, which was first sung in 1955.

It is striking that so many of the tropes and themes concerning what has gone wrong with the world, from our perspective, were already apparent and received clear expression from 1939 through to the mid- to late-1950s, in terrible events, then in thought, poetry, and protest song, in an age of anxiety.

If there are similarities between Auden’s age and our own, then we should be encouraged by that.

Sociologists described the ‘lonely crowd’ in 1950. This suggests that people seek more approval and acceptance from others as the physical distance between them diminishes and society becomes increasingly geared toward consumption. The capacity to come together for peace, remembrance, and unity becomes far less likely.

Philosopher Max Picard lamented the loss of the ’World of Silence’ in 1952: the capacity to be still. And later, in 1958, the word ‘meritocracy’ was first used to describe a dystopian world in which merit (IQ + effort) reigns, replacing previous relational bonds, a sense of togetherness, exemplified in the gathering in Oxford in 2024.

C. S. Lewis, in Oxford in the late 1950s, identified friendship as a kind of love which is regarded 'in the modern world' as 'quite marginal; not a main course in life's banquet', which is especially true if we bypass the banquet and spend our time at the bar (or, worse, online, at home). Louise Gordon, at the vigil, also spoke of the way in which people were counterculturally 'clasping hands in friendship'.

When sociologists today describe the ‘lonely century’ (Noreena Hertz) or when so many sigh over our inability to sit, or stand, in silence, in some sense at least they have not identified anything new. War crimes are, sadly, all too familiar to us. And recently, the lawyer Stephen Toope identified an ‘age of anxiety’ today.

It is not as simple, however, as saying that we have been anxious for the last seventy years. Auden’s age was also one of creativity of which the Anglosphere has been proud, for instance, around the foundation of the National Health Service in 1948. His generation stared into the abyss. They did not die in their dread.

If there are similarities between Auden’s age and our own, then we should be encouraged by that. Lamentation is as old as love, and the choice is as stark as he put it in his poem 85 years ago: ‘love one another or die’.

The notion of vigil is equally old. Today, vigils are held for peace, remembrance, and unity. In Christian liturgy, however, a vigil is specifically a watch during the night, looking forward to the dawn of a new day. ‘As the night watch looks for the morning’, likewise the people wait for Christ, their saviour.

That silent watch is far removed from the solitary ‘faces along the bar’ who ‘cling to their average day’. Horrible events such as those which took place on September 1st, 1939 or October 7th, 2023 bring people together in common purpose, simply to be together and to cling instead to hope for a better tomorrow.

Anxiety is replaced by hope.

Candles are lit. It may well rain. But song will be sung. And people of good-will, having climbed ‘the cross of the moment’, will show what Auden described: that great ‘affirming flame’.