Article
Assisted dying
Comment
Politics
7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

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. 

Essay
Comment
Identity
Nationalism
Politics
15 min read

Could a constitution capture the essence of Englishness?

A proposal for St George’s Day.
A St George's Cross flag flutters on a tower.
St Helen's Church, Welton, Yorkshire.
Different Resonance on Unsplash.

Somewhere behind the concrete-and-glass façade of modern official Britain, one can still find some traces of England: folklore and folk music, country customs and local traditions – wassailing, maypoles, cheese rolling and bounds beating – that neither brutal 19th century industrialisation nor callous 20th century deindustrialisation could completely erase.  

This idealised ‘Quaintshire England’ lurks somewhere in the psycho-geographic triangle formed by Anthony Trollope’s Barchester, Thomas Hardy’s Casterbridge and Geraldine Granger’s Dibley. It is always indeterminately, reassuringly, old. It has a lot of past, but not much future. Yet its traditions are neither stagnant nor dying. Take, for example, the recognition of St George’s Day. Once upon a time, and not so very long ago, St George’s Day came and went with hardly anyone noticing. It was relegated to handful of nasty, shaven-headed, right-wing cranks. Now St George’s Day is marked by respectable newspapers and by the media classes, through the annual ritual of the Great Debate About Englishness.  

For those not familiar, the Great Debate About Englishness takes the form of a stylised conflict between two sides: the Guardians and the Telegraphs. The Guardians start, with a stick-knocking assault on Saint George and all his works: he was Turkish (or, better still, Palestinian); he never visited England (which is just as well, because, as they are eager to insist, England does not really exist anyway, and if it did it would be hopelessly white and racist). Then the Telegraphs move forward, with Scruton bells on their toes, to lament the fact that we no longer celebrate St George, and how all the ills of the world are the fault of the kind of people who say ‘Mumbai’ when they mean ‘Bombay’. At this, the Guardians caper forth, wielding Billy Bragg quotes about ‘progressive Englishness’ in an intricate manoeuvre known to afficionados as a ‘Full Toynbee’. This done, the Guardians retreat before the onslaught of the Telegraphs, who counter-attack with the clincher than English is an ethnic marker, which necessarily excludes anyone whose ancestors were swarthier than a Flemish Huguenot. So concludes the ritual, which is then forgotten about until the following year. 

England, becoming everything, has thereby become nothing. It is the only nation in the United Kingdom without a political life of its own. 

These cathartic ritual confrontations rarely acknowledge that debating the nature of Englishness is itself a symptom of the English nation’s statelessness. Like Kashmiris, Kurds and Uyghurs, the English must debate the nature of their existence because England is – to borrow the term used by Austrian Chancellor Metternich to refer to pre-unification Italy – ‘a geographical expression’.  

The institutions, symbols, and icons of political identity are all British. Despite its historical position at the core of the Union and the Empire, England remains a curiously under-developed nation in constitutional terms. It has almost no formal recognition as a national community. Indeed, England’s dominance over the United Kingdom has had the paradoxical effect of denying England – as England ­– a voice in its own affairs. England, becoming everything, has thereby become nothing. It is the only nation in the United Kingdom without a political life of its own. There is no English Government, nor English Parliament. Even the banal markers of national identity that people might have in their pockets, like coins, stamps, and passport, are British, not English. The absence of such markers means that English identity has high barriers to entry. In other words, we obsess about the ethnic and cultural boundaries of Englishness, because there is no English civic, legal, or political community – let us call it a ‘constitutional community’ – of which one can be a member as a matter of legal right.  

Such a ‘constitutional community’ could take two forms. It might take the form of an independent England, re-founded as a nation-state after Scotland, Wales and Northern Ireland have freely gone their separate ways. Alternatively, given the need for collective defence and international clout in a dangerous world, it could take the form of an England which remains one of four constituent states in a voluntary, equal, confederal Union.  

Either way, an English constitution, understood as a codified supreme and fundamental law, should establish political institutions of England’s own: an English Parliament, an English government, an English judiciary, and an English civil service. Only by this constitutional means can England, now that the British Empire is no more, become a normal nation, make peace with itself, and re-find its place in Europe and the world.  

In part, this is a matter of good government. As the great post-war Commonwealth constitutional scholar Sir Ivor Jennings famously put it, ‘A Constitution is but a means to an end, and the end is good government.’ An English constitution would enable the renewal of a system of government that has become too centralised, too top heavy, and long overdue for reform. It would clarify the rules of political life where these have become contested, reinforce the boundaries of power where these boundaries have been pushed to breaking point, and restate the principles of public ethics which have been neglected. It would protect democratic institutions and norms from erosion by unscrupulous authoritarian populists.  

A list of priorities for consideration in an English constitution, enjoying support across the broad centre of the political spectrum, might include devolution to English cities and counties, electoral reform, reform of the Lords, codification of parliamentary conventions to limit the abuse of Crown Prerogatives, strengthening of the civil service and rebuilding of lost state capacity, restoring standards in public life, and better protection of civil liberties.  

If you are reading this in England...  you are probably not very far away from a place where old stones echo with the words and songs, the faith and the prayers, that have held the English nation together. 

Yet constitutions are more than dull, dry, legal charters of government. They are also national covenants. They set out a vision of who we are, who we want to be, what we stand for, and what we will not stand for. Aside from all the mechanical, institutional, provisions one expects to find in a written constitution, constitutions also contain what we might call metaphysical provisions: those that bear the identity, and bare the soul, of the nation. An English constitution would help to anchor English identity in the midst of changing times. 

While the mechanical constitution is in need of reform, England’s ‘metaphysical constitution’ is not so lightly to be tinkered with. It represents a mystical union of past, present and future, embodying an idea of English nationhood – and English statehood – stretching back to Anglo-Saxon times. At the heart of this metaphysical constitution is the ideal of Christian monarchy, institutionalised through constitutional relationships between the church, state, Crown and nation.  

While the institutional structures of the mechanical constitution are British – and essentially imperial, rather than national, in character – the metaphysical constitution has remained steadfastly English. The Church of England is the only major all-England public institution. The General Synod, which has power to enact Measures having the force of law in England in relation to ecclesiastical matters, is the only England-wide legislative body. England (not Britain, nor the United Kingdom, nor the British Empire, but something older and deeper) can most readily be found in its great cathedrals: Salisbury, Norwich, Wells, Lincoln, Ely, Gloucester, Hereford, Durham. It can be found, too, in the abundance of ancient village parish churches with hand-tapestried hassocks, musty smells, memorial plaques and an almost tangible presence of congregants gone by. England is etched in the moss and lichen of their old gravestones. It is haunted by the Ghosts of England Past, speaking the words of the Book of Common Prayer and the King James Bible. If you listen carefully, you can hear them. If you are reading this in England, even in the midst of a busy city, you are probably not very far away from a place where old stones echo with the words and songs, the faith and the prayers, that have held the English nation together over the centuries. 

Confusion arises, however, from the failure to distinguish between the mechanical and the metaphysical aspects of constitutions. 

That heritage is valued not only by Christians, but also by those who are not believing or practising Christians, but who are pleased to belong to a culture that has been shaped by Christianity. Cutting the Church totally loose from the state, by disestablishment, would abandon custody of this cultural and social heritage to a merely private organisation, having no public recognition, patronage, or connection to the national community. That would be a particularly savage form of cultural privatisation. 

England’s metaphysical constitution is mostly buried beneath the accumulation of ages. If you are good with the constitutional trowel, however, and know where to dig, it is not hard to unearth it. Sometimes it even pokes above ground, as easily seen as the billowy bench of bishops in the House of Lords. The topsoil of modernity is dramatically stripped away at the coronation, when the king swears not only to govern ‘according to the statutes in Parliament agreed on and the Laws and Customs of the same’, and to ‘cause law and justice in mercy to be executed in all [his] judgments’, but also to ‘maintain the laws of God, the true profession of the gospel, and the Protestant Reformed Religion established by law’. The King’s covenant with God and the nation is outwardly and visibly signified when, at the climax of the ceremony, he is anointed, by the Archbishop of Canterbury, with holy oil.  

Thus, the descendants, according to the flesh, of Anglo-Saxon kings, become at their coronation the descendants, according to the spirit, of David and Solomon. The birth of this metaphysical constitution can be traced to the baptism of King Aethelbert, the first Anglo-Saxon king to become Christian. As Bijan Omrani notes, in God is an Englishman, this act transformed the nature and expectations of English kingship, from pagan warlordism to a holy kingly office, responsible under God for bringing God’s peace and justice to England.  

All this is very strange, and easy to mock. To paraphrase a famous scene in Monty Python’s ‘Holy Grail’, ‘supreme executive power derives from the confidence of the House of Commons, not from some farcical aquatic ceremony’. From a purely mechanical point of view, that is of course quite right. As Walter Bagehot’s The English Constitution said of Sir Robert Walpole, the first modern Prime Minister, ‘he ruled England because he ruled that House’. Confusion arises, however, from the failure to distinguish between the mechanical and the metaphysical aspects of constitutions. Many constitutional conservatives, eager to uphold the metaphysical constitution of England’s Christian monarchy, set their face against even moderate and beneficial reforms to the mechanical constitution. On the other hand, many constitutional reformers, eager to mend the broken mechanical constitution, would pave over the metaphysical constitution with all the misplaced zeal of a solar farm company. 

The established church is a particular target of the reformers’ wrath, evidenced most recently by a proposed amendment to the House of Lords (Hereditary Peers) Bill, seeking to remove bishops from the upper House. According to Lord Birt, former Director-General of the BBC, ‘Embedding the Church of England in our legislature is an indefensible, undemocratic anomaly.’ There are only two countries in the world, so we are informed, where clerics sit of right as legislators: the United Kingdom and Iran. The clear implication is that this connection puts the United Kingdom in bad company, as if having a couple of dozen bishops in the House of Lords were comparable to the rule of Ayatollahs. 

Incidentally, remarkably incurious of comparative practice, the people who say this always forget about Belize: a relatively stable and well-functioning Westminster Model democracy, whose tiny upper House includes a Senator nominated by the Belize Council of Churches and Evangelical Association of Churches. They also forget about tiny Tuvalu, a democratic Commonwealth Realm in the South Pacific, where the established church was planted by the London Missionary Society. Perhaps these examples do not fit the narrative that insists that church establishment must inherently be regressive and anti-democratic. 

To those of us who must live also in the here-and-now, not only as Christians but also as citizens of a particular nation and polity, it all looks very bleak.

Even without deliberate abolition, we must nevertheless admit that the metaphysical constitution of England, no less than the material constitution, is in crisis. The most recent census showed that, for the first time since the conversion of Anglo-Saxon England, Christians are now a nominal minority. Of course, the invisible church of born-again Spirit-filled believers was probably always a minority of the population, in England as in any nation. Nevertheless, from the Early Middle Ages until just a few generations ago, nominal Christianity was the norm, and Christian ideas held sway over the narratives, ethics, and assumptions of English society. Not everyone conformed to a model of Christian holiness and goodness – far from it – but there was a common view, shaped by the pervasive cultural, social, and educational influence of Christianity, of what holiness and goodness looked like

That Christian consensus is what has been lost in the social and demographic change – some might call it, a cultural revolution – since the 1960s. The Church of England is still doing excellent work in parishes up and down the land, multiplying the loaves and fishes of its limited resources to provide everything from foodbanks and debt advisory services to parent-toddler groups and pensioners’ clubs, filling the social gap that a failing state no longer even tries to fill. Yet, numerically, the Church of England – except in a few bright pockets of revival – is in free-fall. In the lands of St Ethelbert, St Edmund, and St Cuthbert, empty church buildings have been turned into private houses, gyms, carpet warehouses, soft play centres, mosques, pubs and nightclubs. Looking at things through a spiritual rather than natural lens, we should not be discouraged. We can of course have confidence that the risen King has triumphed, is triumphing, and will ultimately triumph – reconciling all things to the Father, and restoring the whole cosmos to glory. Nevertheless, to those of us who must live also in the here-and-now, not only as Christians but also as citizens of a particular nation and polity, it all looks very bleak. It is a spiritual trial, but a civilisational tragedy. 

Christianity – in particular in the form of mainline Protestantism - has provided the moral, ethical, sociological and institutional props on which constitutional democracy in the Anglosphere was built. Remove those props, and the whole edifice becomes a lot less stable. When we look at the egregious behaviour of Trump and his ilk, we get a taste of how rotten pagan politics would be, unseasoned and unpreserved by the salt and light of Christianity. 

This is, of course, is not to say one cannot have democracies in societies where Christianity has been less historically prevalent. Democracy can exist in a wide range of religious cultures, including in majority Muslim, Hindu and Buddhist societies. Nevertheless, at least within the Westminster Model, it depends upon an institutional subculture - a set of norms, values, traditions, expectations - which, even if successfully transplanted and adapted to different contexts, owe a lot to the kinds of Christianity that emerged from the English Reformation. The restoration of England’s Christian metaphysical constitution is, therefore, integral to restoring the health of the democratic mechanical constitution. By the works of the law – even constitutional law – shall no flesh be justified. Any constitutional refoundation of English democracy worthy of the name must be led and accompanied by a revival of the English Church and by the re-evangelisation of the English people.  

The cross atop the crown represents the principle that public authority has itself been humbled and crucified; the state exists not to be served but to serve the public

his case must be made with careful nuance. It could be misconstrued as an apology for Christian nationalism. Sadly, those who make the most noise about ‘Christian values’ all too often seem, judging by their attitudes and actions, to be reading a different gospel – one from which the Magnificat and the Sermon on the Mount have been expunged. It is galling to watch far-right authoritarian reactionaries parading their Christianity for public display, while pursuing compassionless policies that hurt the poor, the disabled, and outsiders.  

A restoration of England’s Christian metaphysical constitution would not limit freedom of religion, nor diminish the equal rights of all citizens regardless of their religion or lack thereof. The principles of religious liberty and non-discrimination, which go back to Catholic Emancipation and to the repeal of the Test and Corporation Acts in the early nineteenth century, should be guaranteed. Rather, establishment would simply give honourable public recognition to the place of Christianity in the nation’s heritage, grounding the state upon a core of shared Christian values, norms and traditions. If that core is maintained, tolerance and diversity can be built upon it, without undermining the nation’s historic character. In practice, this might involve a more prominent role for Christianity in public life. Public authorities might pay more attention, in their official pronouncements, to the church calendar, and less to those of other faiths, or of post-Christian causes. There might be a more obvious Christian influence in education. One of the by-products of the 1960s cultural revolution is that the clergy have retreated into a narrowly defined churchy role: the academic and the school master in holy orders have all-but vanished. Public broadcasting, too, might return to the broadly Christian assumptions of Lord Reith.  

One of the constitutional functions of an established church is to act as a reminder: to remind the King, Ministers, parliamentarians, civil servants, judges, magistrates, councillors, police constables, teachers, opinion-formers, and every citizen, that to govern is to serve. The cross atop the crown represents the principle that public authority has itself been humbled and crucified; the state exists not to be served but to serve the public. Without such a concept of ethically responsible servant leadership – grounded upon truth, justice, and compassion – democracy can easily deteriorate into cruel, crude, and crass populist perversions of itself.  

Another constitutional function of an established church is to remind us what freedom is for. If applied as mere abstractions, shorn from the Christian root from which they have sprung, and the teleological objectives towards which they point, human rights – valuable as they are – can produce absurd results, actually harming, rather than protecting, freedoms of conscience and expression. Taking the metaphysical constitution seriously again would certainly mean interpreting and enforcing our human rights laws in ways congruent to the Christian principles upon which they are based. After all, it is very odd, in a country where the king has sworn to maintain the true profession of the gospel, that people are being arrested for silent prayer, and that local councils are trying to ban street evangelism. 

Finally, the metaphysical constitution, no less than the mechanical, needs checks and balances. The church cannot perform this constitutional function, as the ethical conscience of the state, if it is – like, say, the Russian Orthodox Church – dependent upon the state. The establishment of the church must not, therefore, compromise the autonomy of the church, to govern itself synodically, and to choose its own bishops. The current process of episcopal selection through the Crown Nominations Commission might leave much to be desired, but going back to the days of political appointment by the Prime Minister is not a viable option. Rather, the principle should be acknowledged, at a constitutional level, that – in the words of Magna Carta - Anglicana ecclesia libera sit: the Church of England shall be free. If we can create constitutional rules that enable judicial independence, and the impartiality of bodies such as the Electoral Commission, we should be able to square this constitutional circle, too.