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

Creed

Ethics

Politics

20 October 2025

7 min read

The Danish Prime Minister is right - the West needs a spiritual rearmament

Christianity should challenge, not reflect, the cultural zeitgeist

Graham Tomlin

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

Mette Frederiksen gesture as she delivers a speech.

Mette Frederiksen speaking at Aalborg University.

Aalborg University.

For some time, there has been a sense of crisis in Europe. You can feel it. European nations are re-arming themselves as America turns off the financial tap. They are struggling to manage levels of migration. Young people are losing faith in democracy.

Yet this is not primarily an economic crisis, or even a political or ethnic one. It is spiritual. And when you start to look for it, you see the signs of it everywhere.

Take one example. Back in the summer, Mette Frederiksen, the Prime Minister of Denmark announced a national military build-up involving increased defence spending, conscription and so on, all fuelled by the general north European fear of expansionist Russia. While speaking to a group of Aalborg University students soon after, she surprised everyone by saying:

“We will need a form of rearmament that is just as important (as the military one). That is the spiritual one.”

She spoke of the discernment needed to tell the difference between truth and falsehood in a world where they were hard to tell apart - and implied this required spiritual wisdom not more technology. Increasing levels of conscription is one thing, but persuading young Danes to fight and even die for anything is another. The problems are not unique to Denmark. Why would Gen Z fight for an economic system that doesn't seem to be working in their favour, doesn't offer them the prospect of owning a home or a stable job, and offers little to inspire any kind of heroism? John Lennon imagined a world with “nothing to kill or die for.” If there is nothing you would die for, there probably isn’t much to live for either.

Frederiksen’s call is just one sign of the spiritual crisis in Europe. Another is the rise of what is sometimes called ‘Christian nationalism’. Elites may sneer at the flags on lamp posts and the crosses held aloft in populist marches, but these are the visible signs of swathes of people in the UK who feel no-one listens to them, and who regret the loss of the cultural and broadly Christian framework that in the memory of past generations provided the operating system of British life for centuries. Its disappearance since the 1960s and the lack of anything to replace it is a problem. The ‘new atheism’ was an act of cultural vandalism, aiming to destroy faith but with nothing to put in its place. You don't have to believe that Tommy Robinson or even Nigel Farage is the answer to this yearning to recognise the validity of this sense of loss.

Yet another is what has been called the ‘Quiet Revival’ - signs of renewed churchgoing among (especially) young men in the UK. Revivals of religion usually happen when a community feels its identity and survival is under threat. At such times, people go back to their roots, to available sources of wisdom and reassurance. This isn't yet a wholesale turning to the Church, but it is sign of a yearning for some kind of spiritual meaning, for something sacred – something that can't be bought for money and that has a value beyond what we choose to give it.

So - back to Mette Frederiksen’s surprising call for spiritual renewal in her own country. Denmark is one of Europe’s most secular nations, Frederiksen is not known as a regular churchgoer, and her Social Democrat party has generally been lukewarm about religion in recent decades. Yet she was honest enough to recognise the problem. If we have told ourselves for decades that there is no such thing as truth, it's not surprising we find it hard to tell truth from falsehood. When we have confidently proclaimed that the most important voice to listen to is our own desires – ‘you be you’ – it is not surprising that that we don’t have any ideals left to live or die for. Young people might take to the streets over climate change or Palestine, but being willing to lay down their lives for something beautiful, sacred, something transcendent beyond all that - even when it has sustained their civilisation for generations? Probably not. And there is no reason to think that Denmark is any different from any other European country. The same is surely true in Britain, even if our politicians are not as perceptive as Mette Frederiksen in noticing the problem.

So where is an answer to be found? Mette Frederiksen called out to the Church for an answer:

“I believe that people will increasingly seek the Church, because it offers natural fellowship and national grounding… If I were the Church, I would be thinking right now: how can we be both a spiritual and physical framework for what Danes are going through?”

Yet herein lies the problem. The Church of Denmark, one of northern Europe’s Lutheran churches, is not exactly in a great state. 70 per cent of the population may be registered members of the church, but only 2.4 per centof those actually turn up in church on Sundays – which makes for an average of 30 people in any local Danish Lutheran church on Sunday.

In Ireland, the Roman Catholic Church ordained just 13 priests this year. Fifty years ago, 90 per cent of Irish people went to mass every week. Now it’s around 16 per cent. The decline was a self-inflicted disaster as scandals of abuse and cruelty recurred with depressing frequency. The Church of England’s attendance figures are not much more encouraging. And its ability to offer something to live and die for is far from clear. The philosopher John Gray is scathing about the western churches’ captivity to the spirit of the age. He thinks of them as “mirroring the confusion of the zeitgeist rather than offering a coherent alternative to it… this kind of Christianity is a symptom of the disease not a cure for it.”

That may be the problem - but it is also the opportunity. Christianity is the west’s default spiritual tradition. Nothing goes as deep into the European soul as this. Others come and go, but this faith is in our veins, our landscape, our art and our memory. Time and again, from its early centuries, it has inspired countless people to live lives of selfless devotion. It happened when the Byzantine empire emerged from the ruins of the Roman one, when a new medieval Christianised civilisation grew out of the ruins of the barbarian conquests, or in the reform movements of the sixteenth and seventeenth centuries, or the missionary movements of the nineteenth centuries. Time and time again it has proved a catalyst for wisdom to face the challenges of crisis, for individual self-sacrifice, cultural renewal and a purpose beyond personal fulfilment – something to live - and die - for.

And it still does. You only have to recall the 21 Libyan martyrs – mostly ordinary Coptic Christians from a simple Egyptian village who were captured by ISIS in 2015, and who chose a gruesome death rather than forsake their faith in the love of Christ – to show how Christian faith gives something not to kill – but to die for.

I have no doubt Christianity can provide that again. Not as a reversion to something past, but in a new form that is true to its roots, but in a way that will look new – maybe humbler, simpler, purer.

This is the challenge for such new leaders as Pope Leo and soon-to-be Archbishop Sarah Mullally. And indeed, for all of us who call ourselves Christian. Can we Christians, as John Gray put it, offer a coherent alternative to the confusion of the zeitgeist rather than be a pale reflection of it?

The future, not just of European Christianity, but also of Europe may depend on it.

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 a gift now