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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Migration

Politics

Romance

3 July 2025

5 min read

Families like mine are impossible now, thanks to the idol that is the net migration target

Politician priests are making pointless sacrifices on the altar of numbers

Joel Pierce

Joel Pierce is the administrator of Christ's College, University of Aberdeen. He has recently published his first book.

A Border Force officer wears body armour with Immigration Enforcement written on the back

UK Border Force.

Let me tell you a love story. Eighteen years ago, in a time before politicians had taken to immolating their values on the altar of the semiannual net migration totals, I fell for the pretty Scottish bridesmaid at my sister’s wedding. The romance presented some challenges for an American like me, but none that were insurmountable. She found a year-long internship near me in Seattle and, just before she returned home, I popped the question.

The process of applying for a UK visa was just another bit of the tedious logistics of an overseas move, the kind of thing a romantic comedy skips over with a ‘One Year Later’ movie subtitle so that it can end with a joyous wedding ceilidh in a picturesque Scottish locale. Our first few years together in Edinburgh were lean ones. Having takeaway coffee more than once a week felt like a scandalously indulgent luxury. Even so, I was able to progress seamlessly from my marriage visa to indefinite leave to remain, to citizenship.

None of this would be possible if we were young twentysomethings in love today. We would fail every test of what the Home Office now considers to be acceptable romance.

During our first year of marriage, the stipend my wife received while training for ministry would have been well short of the £18,600 income threshold introduced in 2012 for a sponsoring spouse, let alone the £29,000 required now. While we did have some savings, they were nowhere near the £88,500 now needed to waive the income requirement, and, in any case, would have been substantially drained by the £5,000 in fees and health surcharges that a two-and-half-year spouse visa now costs. It is little wonder Brits who have found love abroad, even ones in a substantially better financial and professional position than we were then, are now finding it impossible to move back to the UK.

What is the cause of these new barriers? A hint can be found in the title of a recent Guardian article about recommendations for a slight relaxation of the income threshold to between £23,000 to £25,000. ‘Lowering UK’s income requirement for family visas ‘would increase net migration’, the piece was headlined. When even the most left wing major daily in Britain can’t report on the possibility of things being marginally easier for Brits who have the temerity to love a non-citizen, without framing it in terms of net migration, it’s a sign that we have all fallen captive to this singular statistic.

Net migration is a number created by humans and yet it has come to play the role of an angry god which demands sacrifices every time it is reported. The right of working class people to marry a non-citizen spouse, the economic viability of our universities, and the proper staffing of the NHS are all victims its politician-priests have offered up in hopes that they would satiate its hunger. Net zero maybe next.

There is no particular reason to think totting up the total number of people who arrived in the UK with the intention of staying here for a year and then subtracting the total number who left with the intention of staying abroad for a similar duration is a particularly meaningful exercise. It conflates people like me, who came here with every intention to settle and start a family, with students coming for a one-year master’s, doctors filling vital roles in NHS with children try to stay with with a migrant parent and Afghan refugees seeking long-term sanctuary with oil workers serving time in Aberdeen before moving on to Calgary or Brunei.

The dominance of this statistic in our discourse has warped our moral discernments.

There are perfectly legitimate reasons to think carefully about how much of each form of migration to allow, but when they are all grouped together under this single measure a peculiar logic sets in. Want to do the right thing by welcoming refugees from Ukraine and Hong Kong? Well, then, we’ll have to offset that with restricting visas for overseas students and throwing our higher education sector into chaos. Need more highly skilled programmers working in banks in London? Well, maybe we can balance that by demanding care workers abandon their kids if they want to look after someone in Nottingham. There is no reason to weigh the needs of these different sectors against each other, and yet the logic of this statistic demands that we do.

The Bible has a word for human-made things which take on their own singular, violent logic. It calls them idols. While that word may conjure images of golden calves, the accusation which biblical writers consistently make against idolaters, that their idols blind them to what is really important and numbs their critical thinking, applies equally well when the idol is a statistic. The dominance of this statistic in our discourse has warped our moral discernments. It has made us unable to say what should be said without glancing nervously at its imposing shadow. It causes us to say things that should never be said and not notice how absurd they are.

Instead, we should be able to celebrate that hundreds of thousands of people want to come to study at our universities (the vast majority of whom return home after finishing their studies) and, hopefully, someday also be able to celebrate when hundreds of thousands of refugees are able to return to a peaceful and liberated Ukraine without having to calculate that the former will raise and the latter lower our totals. We should be able to welcome easing of income restrictions on spouse visas without noting that it will lead to a marginal increase in net migration. We should be able to see that sending an eight- and eleven-year-old back to Brazil without their parents is not, in the words of a Home Office official, “a degree of disruption in family life” which is “proportionate to the legitimate aim of maintaining effective immigration control”, but rather a gross violation of human decency.

Migrants are not just numbers on a balance sheet. The diversity of our lives, what we give to the UK, what we receive in return, cannot be summed up in a single annual figure. And yet every six months, as the figure comes out, politicians express disappointment and announce measures to put that little bit of extra pressure on us, so that maybe a few more of us who can leave will. In the process they are sacrificing to this idol not just the peace of mind and the economic well-being of many migrants, but also much of the vitality of the nation as a whole. The Bible has a solution for idols. They are only fit to be melted down, destroyed, and forgotten. It is time to consider giving this one a similar treatment.

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