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

Belief

Church and state

Comment

Politics

6 August 2025

6 min read

Danny Kruger, Christian values, and the dangers of thin religion

Thick or thin? Christianity’s role in Britain’s cultural crossroad

Graham Tomlin

Graham is the Director of the Centre for Cultural Witness and a former Bishop of Kensington.

A backbench MP stands in an almost empty chamber and speaks

Danny Kruger addressing Parliament.

Parliament TV.

In case you hadn’t noticed, a speech given to an audience of about seven people in a sparse House of Commons recently went viral. Danny Kruger’s recent call for a Christian restoration in the UK has generated a lot of attention.

I've noticed two distinct responses in recent days. On one side, there are three (or more) cheers for Danny. He has been interviewed at Christian festivals, lauded for a brave, deeply considered and soulful appeal to the Christian heritage of the nation. He has been thinking deeply about this for some time as demonstrated in his book Covenant, sometimes seen as a manifesto for a renewed Conservatism based around the claims of family, community and nation, and summarised in this Seen & Unseen article. As one of the most prominent voices against the recent bills to permit assisted dying and the termination of full-term embryos, he is clearly reeling from the impact of these devastating recent votes in the Commons that, more than anything else, seem to demonstrate how far the nation has slipped its Christian moorings.

Yet it’s not hard to stumble across another reaction. A former Bishop of Oxford called Kruger’s claim that the UK was a Christian nation anachronistic and counter-productive. Others have pointed out that many Jews, Muslims or hardened atheists would not be delighted to be told that ‘it is your church and you are its member.’ Others question whether there can be such a thing as a 'Christian nation'.

Some have picked up on a darker side to all this. Recent riots outside hostels for immigrants in Rotherham and Norwich showed protesters carrying flags of St George, even brandishing a wooden cross. Stephen Yaxley-Lennon, aka Tommy Robinson, and Nigel Farage have recently been speaking much more openly about the ‘Christian values’ on which Britain is founded, and many on the extreme right seem to have latched onto Christianity as at the heart of what they see as a cultural, civilisational war. Kruger’s talk of the gap left by Christianity’s demise being filled by Islam and, what worries him more, a kind of ‘wokeism’ that blends ‘ancient paganism, Christian heresies and the cult of modernism’, sets up a stark opposition. He goes on: “That religion, unlike Islam, must simply be destroyed, at least as a public doctrine. It must be banished from public life.” Does that language stray a bit too close to the aggressive language of more extreme voices on the right?

Now I have some sympathy with this. I have written before of how I also fear the pagan gods are making a return. Like Danny Kruger, I too believe the recent votes in the House of Commons are a dark and dangerous turn toward death not life. Yet I can’t shake a nervous feeling that, without some careful thought, we might be summoning up shades we might not be able to control.

The signs – and the solution - lie in the past. For centuries, Christianity, like all other religions, has been used as a weapon in civilisational wars. It happened in the Crusades of the eleventh to thirteenth centuries. It happened in the Balkan wars involving Serbia, Croatia and Bosnia in the 1990s and 2000. It happened in the ‘Troubles’ in Northern Ireland, where your neighbour being Protestant or Catholic was a reason to kill them.

Theologians and sociologists sometimes talk of ‘thick’ and ‘thin’ religion. ‘Thin’ religion is simply a badge of identity. It often blends religion, politics and nationalism and serves as a motivation to unite people around a cause, such as Hindu nationalism, Muslim victimhood, or Christian supremacy. It is religion seen purely as a label, a badge of tribal identity over against other religious identities, however deeply felt. It is often nostalgic, ranged against enemies who are determined to destroy it, denigrating those who are not part of the religion as less deserving of value. It sees the Christian god as one of many gods – our god – which we must fight for against other gods, rather than, as Christian theology has always taught, the one true God who sits above all other gods, the God of the whole earth. It is paradoxically a manifestation of the kind of the kind of culture that Danny Kruger hates: “a return to the pagan belief that your value is determined by your sex, race or tribe.” Tommy Robinson’s faith seems as good an example of this as any. This is ‘thin’ religion.

I propose a simple test. If someone advocates Christian values and regularly goes to church, then they have a legitimate voice.

‘Thick’ religion, however, is different. It is not just a badge of identity, but entails a set of distinct beliefs and practises. It means submitting yourself to the disciplines of the faith. In the Christian context, it a belief in God as Father, Son and Holy Spirit, that Jesus is the Son of God, that he died for the sins of the world, rose again on the third day and will return one day to judge the living and the dead. It involves a serious attempt to live the Christian life, to love your neighbour, and even your enemy, helping the poor and vulnerable, praying regularly, being consistently present at church worship and so on.

Christian hymns have always had a fair amount of militant imagery, from ‘Onward Christian Soldiers’ to ‘Fight the Good Fight’, and more contemporary ones about God ‘fighting our battles’. Yet this has always meant a serious fight against enemies within – pride, greed, anger and spiritual lethargy. When it became focussed on human enemies, as it did in the Crusades, a line was crossed from ‘thick’ into ‘thin’ religion.

It's not always easy to tell the difference between those who adopt thick and thin Christianity. I propose a simple test. If someone advocates Christian values and regularly turns up at church, then they have a legitimate voice, and are worth a hearing. If they turn up weekly to hear the Bible being read, to take part in Holy Communion alongside other people, regardless of their ethnicity, wealth or background, pray regularly, then, we can assume, they are serious about it. They are submitting themselves to the discipline of learning Christian faith, seeking to love their neighbour and trying as hard as they can to love their enemies. They may fail from time to time but these are the signs of someone who has grasped the grace of God which is the heart of Christian faith. Danny Kruger passes that test. Tommy Robinson and Nigel Farage, as far as I know, don’t.

If some shout loudly about Christian values, about the danger of losing the heritage of our civilization and yet show no interest in going to church, living the Christian life, praying or even trying to love their enemies, then we should take what they say with a large pinch of salt. They have no skin in the game.

When the heart of Christianity is hollowed out, it becomes moralism. It becomes the law not the gospel, as Martin Luther would say. The cross literally becomes a stick to beat others with. Paradoxically, it is only ‘thick’ religion that ends up founding and changing cultures. Early Christianity, the kind that converted the western world, was definitely ‘thick’ religion. It was not just a badge of identity. It had a whole set of distinct beliefs and practices that marked Christians off from the pagan world around them. It did not set out to advocate for political causes in the power corridors of Rome, build a Christian civilisation, lobby Caesar for ‘Christian laws’. It set out to produce people with ‘a sincere and pure devotion to Christ’ as St Paul put it, loving God, neighbour and enemy. And they changed the world by accident.

Thin religion is a dangerous thing. It uses religion as a tool for dominance and conflict. It makes sceptics think we need less religion in public life. Thick religion is good religion. It forms good people. It builds healthy societies. It’s the kind we need more of, not less.

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