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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Faith

15 August 2024

4 min read

Faith is no longer a dirty word in publishing

Sarah Perry’s comments suggest a reawakening of concern for its observation.

George Pitcher

George is a visiting fellow at the London School of Economics and an Anglican priest.

A woman being interviewed gestures with a hand in front of her

Sarah Perry.

Waterstones.

If there’s one thing anyone who has ever written a novel can’t stand, it’s having to congratulate a successful novelist. So, it’s through gritted teeth that I warmly welcome the words of Sarah Perry (The Essex Serpent) that religious faith is ceasing to be a subject of embarrassment in published fiction.

It’s about time. Perry told the Edinburgh International Book Festival that, for her latest book Enlightenment, she was asked to put in more theology: “I assumed that everybody knew what the doctrine of predestination meant.” Bless.

The cause of my pathetic envy as I applaud her is that I had my first (and, to date, only) novel published in 2017, to almost universal disinterest. I like to tell people that it was well received – all three people who actually read it said they enjoyed it and only one of them was a family member. It actually did a bit better than that, but you get my drift.

It was an unashamedly religious psychological thriller, titled A Dark Nativity. Brace position, here comes a one-sentence synopsis: The narrator, Reverend Natalie Cross, is a frustrated former aid worker who undertakes a mission to Israel, is kidnapped and held hostage, murders her way to freedom, discovers she was the victim of an Anglo-American plot, wreaks her terrible revenge and (spoiler alert!) gives birth to a son of uncertain paternity.

See what I did there? As well as the latter-day Nativity resonance, thematically I was interested in what redemption looks like in Israel and Palestine. I know, I know – but even I thought it would be distasteful to try to cash in on what’s happened there since.

Enough of the plug for a seven-year-old novel. My point is that its religious themes actively militated against it at the time. Novels addressing Christian faith (or any other kind) occupied a particular publishing niche – a harsher word might be ghetto. To try to break out of it was pointless. The great Christian novelist Penelope Wilcock told me (very kindly) that my book was too religious for the secular market and too secular for religious readers.

Perry’s observation that faith is no longer a dirty word in publishing might yet suggest a reawakening of serious concern for its observation.

The restricted area to which religion was confined had its stylistic rules. There was the cathedral close romp, which authors such as Catherine Fox had made their own. The vicarly whodunnit (lately updated by Reverend Richard Coles). Magic realism with its daemons and Philip Pullmans. And anything, in the wake of Dan Brown’s The Da Vinci Code, involving ancient plots that might make a movie, with hooded figures walking in slo-mo through cloisters.

Vicars had to be evil or silly. I may be both those things at times, but I’d like to think there is other stuff going on here for cultural exploration. My narrator, Nat Cross, was driven, often funny and more than a little mad. So like a lot of Anglican clergy.

If she’s right – and I very much hope she is – it’s why what Perry has to say is so hopeful. Because it begins to suggest that religious faith is slowly beginning to be accepted back into polite society. Whisper it softly, it might even become a cultural norm. If Richard Dawkins can describe himself as a “cultural Christian” and the historian Tom Holland, in his book Dominion, can claim that Christianity is the entire foundation of western civilisation, then there is everything to play for. And, indeed, write for.

It’s not as if cathedral frolics and the revelation of Jesus’s wife in Leonardo’s Last Supper was anything other than a fictional diversion of post-modernism. Religion and specifically Christianity had been a staple of the novel in English.

I hesitate to mention their names in the same column as the authors above (including me, most obviously), but Graham Greene’s exposition of Catholic guilt in The End of the Affair and Evelyn Waugh’s of the impossibility of moral reformation in Brideshead Revisited are probably the best religious novels of the twentieth century.

Further back towards the birth of the English novel, the Reverend Edward Casaubon in George Eliot’s Middlemarch is perhaps the most tragic portrait of a clergyman who is neither evil nor silly. He stand as a warning from history to today’s Church of England.

And it’s to that, the established Church, that Perry’s remarks ultimately turn our attention. We’re told that there has been a five per cent spike in church attendance recently, but that of itself isn’t sufficient to suggest a renaissance in our religious culture. Our arts and culture will only ever really reflect what we care about.

Perry’s observation that faith is no longer a dirty word in publishing might yet suggest a reawakening of serious concern for its observation. If so, that’s good news for the religious, as well as for religious authors. And I might just get a sequel out of it.