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

Comment

Ethics

Politics

War & peace

23 June 2025

5 min read

We must invest in defence, fast - it’s the only moral thing to do

The responsible use of force today precludes pacifism

Emerson Csorba

Emerson Csorba works in deep tech, following experience in geopolitics and energy.

Amid a bombed alley, a victim is helped to walk by a rescue worker

Aftermath of a Russian drone attack, Odesa, Ukraine.

Dsns.gov.ua, CC BY 4.0, via Wikimedia Commons.

In May 2016, I was hiking the Southwest Coast Path in a group, trudging through dense forest between Lyme Regis and Weymouth, when a distinctly unsettling event occurred. As we moved along a narrow trail, a buzzing sound began—we assumed we had disturbed a bee’s nest. We quickened my pace, but the buzzing continued. Eventually, we emerged from the woods and looked up. The sound had not come from bees, but from a drone that had been following us.

I will never forget that sound; the eerie sense of something pursuing you, but unseen. In a recent BBC special on the war in Ukraine, a journalist documents the now-pervasive use of drones, the journalist and Ukrainian soldiers hiding under the cover of forest as a Russian drone scans the area, before escaping to their car in which an AI voice says ‘Detection: multiple drones, multiple pilots, high signal strength’ as they journey overground. This is the new era of covert warfare, where the enemy strikes without being easily identified. You hear the hum, but the source is elusive.

In the coming years, this kind of psychological warfare will make its way into Western cities. Terrorist attacks will shift from in-person confrontations—like the Novichok poisonings in Salisbury—towards remote, anonymous assaults: drones drifting from overseas into coastal cities to target civilians, or swarms carrying out mass attacks in dense downtown cores. The aim will be psychological trauma at scale. Civilians will grow hesitant to leave home, hyper-sensitive to the buzz of anonymous drones in their own areas. Iran recently declared that no US, British, or French base is safe from retaliation in the emerging Israel–Iran war. It is not difficult to imagine Western cities soon being viewed as legitimate targets.

We are entering a time of intensified conflict, with national security becoming the dominant framework for policymaking. The watchword of UK government policy is ‘security,’ and—writing now from Montréal—the recent Canadian election was framed around which party and leader could best protect Canadians from external threat. In this context, even domains once governed by cooperation are transformed into zero-sum contests, because national security framing by its nature shifts focus from reciprocity to limitation of the other.

Free trade, for example - fundamentally the mutually beneficial exchange of goods and services as part of the creation of value - becomes, in a security-focused world, a question of containment. Trade, in a security-focused world, is turned on its head, free trade becoming trade wars. Fairness (in which the pie is grown and shared across multiple people) is replaced by interest, whether the interest of countries or communities and individuals within them seeking to protect themselves. As US–China competition escalates, we can expect human relations—among both states and citizens—to become even more zero-sum.

In such an environment, do morals still matter? When the enemy grows more ruthless and more innovative in an era of national security, must we match them in kind? Or is it still possible to uphold principles while defending ourselves?

Restraint and humility are still critical virtues—but must not be mistaken for weakness.

In a recent Times column, Juliet Samuel suggested that gestures of non-aggression—such as Finland’s 2015 destruction of its one million landmine stockpile—now appear dangerously naïve. Ukraine, for its part, has rightly disregarded the Ottawa and Oslo (banning cluster munitions) conventions. Its survival depends on ingenuity, rapid technological development (for instance through the work of funds such as D3), and collaboration with its allies to prototype and deploy advanced systems.

Reinhold Niebuhr, in Moral Man and Immoral Society, contends that to be moral, one must possess the capacity for force—‘power must be challenged by power.’ That power, however, must be exercised with responsibility, humility, and moral purpose. Nigel Biggar, my former doctoral supervisor and a key figure in the Niebuhr tradition of Christian realism, argues in In Defence of War that war can be justified on balance when it meets the criteria of jus ad bellum: just cause, legitimate authority, right intention, proportionality, and reasonable prospect of success.

War, in this reading, can express a ‘kind harshness’—a form of judgment exercised in defence of victims. Like Niebuhr, Biggar grounds his argument in Augustinian realism: the world is fundamentally good, yet broken. Because evil persists, the moral use of force becomes necessary to uphold what is right. I believe this to be true, and directly applicable to the national security-focused world in which we find ourselves.

What does this mean then for Western countries as national security reasserts itself as the central organising principle of governance?

It means significant and urgent investment in defence and deep technology, including for instance emerging capabilities like cognitive warfare and neuroadaptive systems (wearables that enhance soldiers’ performance in live combat), counter-drone systems for urban, rural, and maritime environments, and next-generation electronic warfare and geospatial intelligence.

If drone attacks intensify at sea—such as those carried out by the Houthis to disrupt global shipping routes—counter-drone systems will be vital to ensure safe passage. In a world of manipulated narratives and disinformation, geospatial intelligence will serve as a source of truth, helping establish what is actually happening on the ground. And as agentic AI grows increasingly capable of manipulating users—through sycophancy, persuasion, and other techniques—oversight technologies like Yoshua Bengio’s new LawZero project will be essential for maintaining objectivity and integrity.

The responsible use of force today precludes pacifism, averting violence altogether. It means maintaining—and advancing—the capability for overwhelming force, so it is ready if needed. Morality in an era of national security demands investment in defence technologies at speed, to stay several steps ahead of adversaries. A ‘whole-of-society’ approach, as recommended in the recent UK Strategic Defence Review, means preparing citizens with such a mindset. Restraint and humility are still critical virtues—but must not be mistaken for weakness. Western nations must be prepared to act swiftly, decisively, and with the deterrent power that peace requires.

This is the world we are entering: one in which governments and civilians alike must be ready for unexpected threats. The hum of a drone overhead is more than a sound—it is instead a warning, reminding not only Ukrainians but those currently in peaceful situations, to prepare ourselves for potential conflicts to come. The appropriate response is not retreat, but the responsible and moral exercise of power: a necessary duty if we are to preserve peace, freedom, and justice in a world increasingly intent on contesting them.

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