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.

Column

Comment

General Election 24

Morality

Politics

2 July 2024

4 min read

Make it a morally decisive election

This week we’re making more than a political decision.

George Pitcher

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

A AI generaed montage shows two politicans back to back surrounded by like, share and angry icons.

The divide

Nick Jones/Midjourney.ai.

I still treasure my copy of the New Statesman from almost exactly 13 years ago, which was guest edited by the then Archbishop of Canterbury Rowan Williams. I’ve kept it partly because I organised the edition and deputy edited it on his behalf. And partly because it cost me my job as public affairs chief at Lambeth Palace after it provoked predictable Conservative backbench fury for his alleged meddling in politics.

Digging it out now, there are some surprises from near that beginning of the 14 years of Conservative rule that’s expected to come to its end this week. The first is how mild mannered is the archbishop’s leader comment that cause so much trouble. In the years since, politics has become brasher and blunter, more facile and reductive.

The second surprise is the fuss it caused at the time. Williams is politely critical of politics across the board and there’s a plus ca change moment when he wonders “what the left’s big idea currently is… we are still waiting for a full and robust account of what the left would do differently”.

And he could be talking about now as he concludes by hoping for a “democracy going beyond populism and majoritarianism… capable of real argument about shared needs and hopes and real generosity; any takers?”

A magazine cover lists articles on one side and an image of half a face on the other.

That final question may get its answer this week. But at this distance, the furore that Williams caused in government takes on a different perspective. We can see, partly as a consequence of what’s happened latterly, that he wasn’t really mounting a political argument at all. His was a moral case, a prophetic voice calling out how the government, any government, “needs to hear just how much plain fear there is.”

That fear hasn’t abated 13 years after that article. It has built around a faltering economy, an island mentality inflamed by the perceived threat of migration and a sense that a political elite has abandoned its people.

Political policies alone aren’t going to salve this pain. The response to it needs to be as much a moral as political one, as caught by the headline I wrote above Williams’ piece all those years ago: “The government needs to know how afraid people are.”

The government in power for the past 14 years has chosen not to address, or has ignored, or has been incapable of addressing the morality of our societal decay, favouring instead a search for eye-catching policies and initiatives that it has hoped, admittedly with some success until now, would also be vote-catching.

That it has now run out of road has as much to do with its moral as its political failure. When Williams published that piece, we were talking about the Big Society, the prime minister was on a mission to save the planet and urged us to “hug a hoodie.” Such moral imperatives seem very distant now and a moral degeneration in government has tracked the downward slide of the governing party in the opinion polls.

So we’re not asked just to make a political decision this week. We’re making a profoundly moral one.

We haven’t had a prime minister for whom morality was a governing principle since David Cameron laid claim to one (perhaps disingenuously) in his early days, before being led by his chancellor, George Osborne, into enforced economic “austerity” with surely one of the most cynical assurances of modern times that “we’re all in this together.”

Brexit did for Cameron and his successor Theresa May. She, I believe, is guided in public life by a personal morality, rooted in her Anglo-Catholic clergyman father, but by now there was no room for all that. Her “hostile environment” for illegal immigrants, with vans telling them to go home, was a moral low point which then found its hideous nadir in the Windrush scandal, with elderly people who had lived here all their lives threatened with deportation.

Boris Johnson thought that he could make a political virtue of his immorality, a demonic possession that made him believe that he’d be loved for it. So he fiddled while Covid burned, partying in Number 10 while those who had voted for him were denied access by his rules to their dying relatives.

I wrote in the Guardian that he wouldn’t be able to hide his immorality in Number 10 when he became leader and was sadly proved more right than I could have known. Liz Truss is said to be on an autistic spectrum, which is the kindest way to explain her mini-budget that offered tax-breaks for the wealthiest in the midst of a cost-of-living crisis for the rest of us.

Rishi Sunak is widely said to be a decent man, but it's too late. This government had already rotted from the head – witness the spivs in its ranks hoping to make a fast buck out of the date of the general election.

So we’re not asked just to make a political decision this week. We’re making a profoundly moral one. It’s time to turn the fear that the archbishop observed into moral indignation.

It’s not really about who we want in government. It’s what we need, morally, to expel from it.