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.

Explainer

Belief

Community

Creed

Politics

10 June 2025

7 min read

The peripheries of belief: how faith shaped the north’s identity

Northern spirituality’s rebellious capacity to adapt is still in play today

Tom Rippon

Tom Rippon is Assistant Editor at Roots for Churches, an ecumenical charity.

Durham Cathedral and town.

David Connor on Unsplash.

2025 has so far been the year of the north. At its start, we were treated to the plasticine escapades of Wallace and Gromit, whose unabashed northern-ness was enough to faze American TV executives. Then in April, the story turned to northern industrial decline when Scunthorpe steelworks hit the headlines, prompting last-minute state intervention. In May, the local elections saw the astonishing rise of Reform across areas previously dominated by Labour. Taken together, these three moments encapsulate the range of associations often evoked by life on the periphery of England: regional pride, good-natured humour, close communities, economic precarity and hard graft.

The north is a landscape of contraries and co-existence, where sweeping fells and dark skies meet red-brick chimneys and rolling waves of terraced houses. As David Barnett puts it, it is “a place made up of individuals, bound by an ethereal quality that is at once a myth and, conversely, as real as grit and graft.’

Hard to pin down, yet real once seen, the same could also be said for the faith that has filled the region with a multitude of expressions to this day.

Of course, when we talk about ‘the north’, we mean everything and everyone from the conurbations of Merseyside and Greater Manchester to the Lake District and Northumberland, where centuries of border warfare have left a plethora of castles and fortified houses (‘pele towers’). Two landscapes dominated by buildings which have long lost their original purposes. Perhaps the principal shared characteristic of these communities is a sense of distance from mainstream political and cultural life (just try catching a train that isn’t heading to London). But with distance comes an independence of identity and a proud sense of cultural distinctiveness. If anything, the only thing that can be definitively said about northern identity is that it is the quality of being ‘not southern’.

Northern Christianity has not escaped this wavering relationship with the south. In 664 AD, the Northumbrian Church gathered at Whitby for a meeting presided over by King Oswy of Northumbria and the Abbess Hilda of Whitby. It was quite literally a pivotal moment for the early Church and the north more widely. The matter at hand was whether Northumbrian Christianity, then centred on the Holy Island of Lindisfarne, should remain orientated towards Celtic Christianity, which had as its principal focal point the abbey of Iona, or whether to turn towards Rome and its growing mission in the south, headquartered in Canterbury. North or south? Canterbury or Iona?

In the end, the group opted for closer links with the Roman Church. Yet the Christian faith in the north remained distinctive, blending the older influences of St Columba and St Aidan with the new ones coming up from the south. Lindisfarne Priory remained a centre for Christian life in the north and its prestige led it to accumulate the wealth that eventually precipitated its own destruction by Viking raids in 793 AD. In spite of this, the northern saints drew reverent pilgrims for centuries to come, as the grandeur and scale of Durham Cathedral, the burial place of St Cuthbert, testifies to this day.

Behind the independent northern spirit lies a long history of political, economic and spiritual divergence from the south. Northern spirituality is characterised by a sustained distinctive flowering of the Christian faith that intertwines itself with the social identity of the peoples and places of the north. The region’s response to the religious reforms of Henry VIII was the Pilgrimage of Grace, which protested both his break from the Roman Catholic Church and socio-economic policies implemented by the king and his chief minister, Thomas Cromwell.

By the seventeenth century, faith in the north had taken on a distinctly reformist hue as non-conformism – that is, churches and sects not aligned with the Church of England, the Church of the state and the establishment – flourished in the region. The beginnings of the Quaker movement can be traced to an open-air sermon given by the reformer George Fox in 1652 on Firbank Fell, near Sedburgh in modern Cumbria - the crag he spoke from is still known as Fox’s pulpit - while other reformist movements, including Methodism, Congregationalism and Presbyterians, also drew increasing crowds with their passionate preaching in fields, moors and disparate farming communities.

The very landscape of northern England, often challenging and remote, drew its inhabitants away from both socio-political centres and the established Church, nurturing forms of belief in the seventeenth and eighteenth centuries which were as independent as those of seventh- and eighth-century Northumbria. Much of religious life in the region was organised around a large parish church that served numerous small communities spread across a large area. Living at such distances, no wonder people felt a disconnect from the parish church and the national Church it represented. Non-conformist chapels and meeting houses quickly spread across the landscape, particularly in remote villages outside of the control of major landowners and Church authorities. As David Petts argues, the building of chapels expressed the collective economic and organisational independence of rural labourers and miners, and united dispersed communities through collective endeavour.

The region has proved itself capable of delivering considerable shocks to the London political establishment.

Once the chapel was built, they would prove valuable training grounds for rethinking the political organisation of the poor; the significance of non-conformism thus lay not only in its spiritual divergence from the establishment, but also in its fostering of alternative political systems. Methodism in particular was to provide an ideological and practical template for mass movements such as Chartism, which campaigned for social reform and an expansion of democratic suffrage in the mid-nineteenth century. Chartist campaigners called themselves ‘missionaries’ and crisscrossed the country preaching ‘the gospel of Chartism’ and forming Chartist congregations. Their political vision found a receptive audience in the working population of the industrialised north, who were raised on the non-conformist emphasis on Christ as the carpenter’s son and a poor man, one who worked for his living as they did. Towards the end of the nineteenth century, the non-conformist social Gospel produced notable reformers such as the journalist W. T. Stead, born in rural Northumberland as the son of a Congregationalist minister, and the Quaker confectioner Joseph Rowntree of York.

Amidst the darkness, grime and crushing conditions of nineteenth-century mills and mines, the Christian message of mutual aid and fellowship, first articulated by the early Church, again found expression. In Manchester, the Methodist Central Hall served a dual purpose, providing a space for worship on Sundays and a community space during the week, when it offered libraries, food, clothing, shelter, childcare and even entertainment to the people of the city.

Social reform and the Christian faith buttressed one another across the region and together resisted the fractures, pressures and degradations that industrialisation exerted on the communities they served. The social values of these interdependent movements left a lasting impact on the modern political landscape of the region, until recently known as Labour’s ‘Red Wall’. As any political correspondent will tell you, northern politics can no longer be taken for granted and the region has proved itself capable of delivering considerable shocks to the London political establishment. Walking through these communities, left behind by deindustrialisation, globalisation and our periodic post-crisis recoveries, the air seems pervaded by a sense of unravelling as the old bonds and certainties slowly slip-away. The Church is not immune to these processes and the north follows the overall national trend of declining church attendance. The empty chapels testify as much to the seismic shifts taking place in the region as the empty warehouses and factories.

But if the history of Christianity in the north tells us anything, then it is that northern spirituality has never stood still. It has an ingenious capacity to adapt, to regenerate itself to meet the challenges faced by each generation. The challenges are varied and specific to each community, but the Church is there. In Burnley, the fight of the early disciples against urban poverty is echoed in the work of the Church on the Street, whilst on Holy Island itself, the Parish Church of St Mary the Virgin is a driving force behind the Holy Island 2050 project, which aims to assure the sustainability of the Island community in the face of depopulation and rural precarity.

If the dominant atmosphere in the north is one of feeling left behind, then the Christian call to reach out to those around us is needed more than ever. More than one thousand years separate St Aidan from us, but the Christian faith can still help the us to navigate the challenges and precarities of a changing world.

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