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

Justice

Leading

Politics

7 July 2025

5 min read

The consequences of truth-telling are so severe our leaders can’t admit their mistakes

When accountability means annihilation, denial is the only way to survive

Leah Brown

Leah is a campaigner for restorative practices and founder of The WayFinders Group.

Baroness Casey.

BBC.

Why do our leaders struggle so profoundly with admitting error?

Media and inquiries regularly report on such failures in the NHS, the Home Office, the Department of Work and Pensions, HMRC, the Metropolitan Police, the Ministry of Defence, and so many more public institutions. Often accompanied by harrowing personal stories of the harm done.

In a recent white paper (From harm to healing: rebuilding trust in Britain’s publicly funded institutions), I defined “harm” as a holistic concept occurring where physical injury or mental distress is committed and sustained and explained that harm is generally something that is caused, possibly resulting in injury or loss of life.

When we look at harm from an institutional perspective, structural power dynamics inevitably oppress certain groups, limit individual freedoms, and negatively affect the safety and security of individuals. But when we look at it through the lens of the individuals who run those institutions, we see people who often believe that they are acting in good faith, believe that their decisions won’t have a significant impact, who don’t have time to think about the decisions they are making, or worse still, prefer to protect what is in their best interest.

Even well-intentioned leaders can become complicit in cycles of harm - not just through malice, but through their lack of self-awareness and unwillingness to put themselves in the shoes of the person on the receiving end of their decisions.

Martin Luther King Jr supposedly said, “the ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” In contemporary politics, leaders are neither selected nor (largely) do they remain, because of their humility. Humility is synonymous with weakness and showing weakness must be avoided at all cost. Responsibility is perceived as something that lies outside of us, rather than something we can take ownership of from within.

So, why do leaders struggle so profoundly with admitting error?

The issue is cultural and three-fold.

First, we don’t quantify or systematically address human error, allowing small mistakes to escalate.

We then enable those responsible to evade accountability through institutional protection and legal barriers.

Finally, we actively discourage truth-telling by punishing whistle-blowers rather than rewarding transparency. Taken together, these create the very conditions that transform errors into institutional harm.

Nowhere is this plainer than in Baroness Casey’s recent report on Group-based Child Sexual Exploitation and Abuse that caused the Government to announce a grooming gangs inquiry. In this case, the initial harm was compounded by denial and obfuscation, resulting not just in an institutional failure to protect children, but system-wide failures that have enabled the so-called “bad actors” to remain in situ.

Recently, this trend was bucked at Countess of Chester Hospital where the police arrested three hospital managers involved in the Lucy Letby investigation. Previously, senior leadership had been protected, thus allowing them to evade accountability. Humble leadership would look like acting when concerns are raised before they become scandals. However, in this case, leadership did act; they chose to bury the truth rather than believe the whistle-blowers.

Until we separate admission of error from institutional destruction, we will continue to incentivise the very cover-ups that erode public trust.

The answer to our conundrum is obvious. In Britain, accountability is conflated with annihilation. Clinging onto power is the only option because admitting error has become synonymous with career suicide, legal liability, and is tantamount to being hanged in the gallows of social media. We have managed to create systems of governing where the consequences of truth-telling are so severe that denial is the only survival mechanism left. We have successfully weaponised accountability rather than understanding it as the foundation of trust.

If Rotherham Metropolitan Borough Council had admitted even half of the failures Alexis Jay OBE identified in her 2013 report and that Baroness Casey identifies in her 2025 audit, leaders would face not only compensation claims but media storms, regulatory sanctions, and individual prosecutions. It’s so unthinkable to put someone through that that we shrink back with empathy as to why someone might not speak up. But this is not justice. Justice is what the families of Hillsborough have been seeking in the Public Authority (Accountability) Bill: legal duties of candour, criminal offences for those who deliberately mislead investigations or cover-up service failures, legal representation, and appropriate disclosure of documentation.

Regardless of your political persuasion, it has to be right that when police misconduct occurs, officers should fear not only disciplinary action and criminal charges. When politicians admit mistakes, they should face calls for their resignation. Public vilification is par for the course. Being ejected from office is the bare minimum required to take accountability for their actions.

The white paper shows that the cover-up always causes more damage than the original error. Institutional denial - whether relating to the Post Office sub-postmasters, the infected blood scandal victims, grooming gang victims, Grenfell Towers victims, Windrush claimants, or Hillsborough families - compounds the original harm exponentially.

In a society beset with blame, shame, and by fame, it is extraordinary that this struggle to admit error is so pervasive. Survivors can and will forgive human fallibility. What they will not forgive is the arrogance of institutions that refuse to acknowledge when they have caused harm.

The white paper refers to a four-fold restorative framework that starts with acknowledgment, not punishment. The courage to say “we were wrong” is merely the first step. Next is apology and accountability followed by amends. It recognises that healing - not just legal resolution - must be at the heart of justice, treating both those harmed and those who caused it as whole human beings deserving of dignity.

Until we separate admission of error from institutional destruction, we will continue to incentivise the very cover-ups that erode public trust. I was recently struck by Baroness Onora O’Neill who insisted that we must demand trustworthiness in our leaders. We cannot have trustworthiness without truth-telling, and we cannot have that without valuing the act of repairing harm over reputation management. True authority comes from service, through vulnerability rather than invulnerability; strength comes through the acknowledgement of weakness not the projection of power.

We must recognise that those entrusted with power have a moral obligation to those they serve. That obligation transcends institutional self-interest. Thus, we must stop asking why leaders struggle to admit error and instead ask why we have made truth-telling so dangerous that lies seem safer.