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

Culture

Digital

Film & TV

Work

24 June 2025

7 min read

What my film about the prodigal son really means

Our relentless focus on productivity devalues the things that make us human

Emily Downe

Emily is designer and animator at the Theos think tank.

In Sync with the Sun.

Theos.

Watch now

In his 2021 book 4,000 weeks: Time Management for Mortals, Oliver Burkeman observes that an obsession with productivity doesn’t give us more control over our lives, ‘instead, life accelerates, and everyone grows more impatient. It’s somehow vastly more aggravating to wait two minutes for the microwave than two hours for the oven - or ten seconds for a slow-loading web page versus three days to receive the same information by post.’

With technologies like artificial intelligence rapidly accelerating our lives, this constant demand to squeeze more into our time is not only limited to the mundane tasks that we have to do and wish we didn’t. It seeps into what we want to do and indeed must do in order to flourish: creating art, spending time in community, and caring for others. The problem is that these things cannot be measured in productivity metrics because they inherently do not function in that way. How do you measure how ‘productive’ a conversation is? Or a work of art? Artists such as Vincent Van Gogh or Emily Dickinson didn’t see their influence in their own lifetime.

The more we measure our lives in productivity metrics, the more we devalue the things that make us human, ultimately making our lives and the world around us increasingly artificial. This is the basis of my recent film, In Sync with the Sun, which is a short animation about the rhythms of activity and rest that are written into our world, and what happens when an obsession with productivity takes over.

I wrote the initial script for the film after a period of burnout. I was fully in the “make the most of every second” mindset, which left me feeling exhausted and confused about where my value resides. In response, I began researching the sleep-cycles of various animals and I was liberated by surprising details such as the fact that lions, which we see as mighty and majestic animals, sleep for around 21 hours a day. Even creatures like jellyfish, which don’t even have brains as far as we know, still have cycles of rest. Every living thing thrives in these rhythms of activity and rest, even down to plants and minuscule organisms. Our whole world is built on this pattern, in sync with the sun. Yet for us humans, our rhythms have been broken by technology, leaving us confused about our limitations and what we should do with our short lives.

The film begins in nature, deep in the jungle where some leopards are sleeping. But the tranquility is abruptly interrupted by the voice-over declaring, “the war against sleep began when artificial broke into the night.” Brilliant white light breaks up the deep blues and purples on screen, until the screen is filled with blinding white. I wanted it to feel like that moment you peer at your phone in the middle of the night - the pain of your pupils trying to adjust. If you think about it, for 99.9 per cent of human history, our eyes would have never had to do that - until now.

Artificial light wasn’t powerful enough to change that. Instead, it’s given us an unquenchable guilt about how we use our time.

With his invention of the light bulb, Thomas Edison was determined to banish the night, and the limitations it enforced on us. Edison was known for being fiercely obsessed with productivity and, as a result, was an anti-sleep warrior who believed,

“There is really no reason why men should go to bed at all.”

As someone living a century on, I find it baffling to imagine that humans should eradicate sleep entirely. Perhaps because just 100 years later we are seeing the results that sleep-loss and over-working can have on our physical health and wellbeing. Maybe we cannot supersede nature after all, since we are an embedded part of it. It seems that “Sabbath" rest is written into our world and into our humanity. Artificial light wasn’t powerful enough to change that. Instead, it’s given us an unquenchable guilt about how we use our time. Now we decide when the day ends, so whoever can rest the least wins.

The battle is still raging; incandescent bulbs only set aflame that root desire to be increasingly productive. The hamster wheel is spinning uncontrollably, and we must keep up. So, what do we do? The attempt to remove the limitations outside of us has revealed that they are in fact inside of us too. Therefore, the only way to keep up is to remove the human from the hamster wheel altogether. The failure of artificial light leads to the birth of artificial minds.

As a creative, this is what frustrates me most about artificial intelligence; that it is mostly being driven by this quest to bring everything under the reign of productivity. It goes without saying that this is greatly needed in some areas of society. Just like artificial light, it can and will do a lot of good in the world. However, when the obsession with productivity is prioritised over human flourishing, that’s when we know there is a big problem with how we view our lives.

Thinking back to the examples of Van Gogh and Emily Dickinson; what is lost when we don’t allow space for artists, carers, mothers, or any skilled role that requires an element of patience? For me personally, I can’t force creative inspiration, instead it comes at me, often at times when I’m not looking for it. Similarly, sometimes that inspiration leads directly to an instant idea, but most often it’s a vague idea I jot down to which later life experiences and opportunities then build onto, forming it into something bigger and more in-depth. This could be compared to a role or situation that requires relationship building. Sometimes there are moments of instant bonding and “productive” progress in relationships, but it’s often more complex where external experiences or changes, which are outside of our control, may unexpectedly deepen understanding between people after long periods of frustration.

In my animation, I used the metaphor of a butterfly to illustrate this sentiment. After the character realises he is not made for a life of relentless productivity, he steps out of the black and white skyscraper into the lush wilderness. A butterfly lands on his productivity badge and the voice over says, “You’re not a machine.” I imagine the Creator saying this to the loved creation. Creatures like butterflies seem completely unproductive to our human standards. They take weeks to form in the chrysalis and exist in the world for less time than that. Yet they are a source of wonder and beauty for anyone who has the privilege of seeing one up close. A reminder that nature is not in a rush. Where AI is concerned, however, speed and profit are the focus of desire. But looking at the world around us - that we are a part of - it’s clear that not everything can or should be valued by these limiting metrics alone.

The overarching narrative of In Sync with the Sun is loosely inspired by the biblical story of the prodigal son. The main character has travelled far away from his home in pursuit of success, and he eventually realises that this master does not love him. At the end he comes home again, finding connection in community and in the good rhythm of productivity and rest that he came from. I wanted the film to address the issues that an unhealthy obsession with productivity can cause, and instead evoke a desire to accept and live more in sync with the boundaries and rhythms that are embedded in the natural world we are a part of.

The film ends with the line, “The only thing that can stay awake is not awake at all.” In the midst of the changing world of AI, humans might be tempted to measure our productivity levels in comparison to these machines. However, technologies always raise the productivity bar higher and higher, and one day we need to accept that we simply aren’t going to be able to reach it. We don’t sit apart from nature like technology does, so let’s stop resenting that, and instead celebrate it. To quote Oliver Burkeman again,

“the more you confront the facts of finitude instead - and work with them, rather than against them - the more productive, meaningful and joyful life becomes.”

Support Seen & Unseen

Since Spring 2023, our readers have enjoyed over 1,500 articles. All for free.
This is made possible through the generosity of our amazing community of supporters.

If you enjoy Seen & Unseen, would you consider making a gift towards our work?

Do so by joining Behind The Seen. Alongside other benefits, you’ll receive an extra fortnightly email from me sharing my reading and reflections on the ideas that are shaping our times.

Graham Tomlin
Editor-in-Chief

Pledge now