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

Assisted dying

Care

Comment

Politics

9 June 2025

5 min read

Suicide prevention groups are abdicating their responsibility on assisted dying

Not speaking out is a dereliction of duty to vulnerable people

Jamie Gillies

Jamie Gillies is a commentator on politics and culture.

Three posters with suicide prevention messages.

Samaritans adverts.

On Friday, Kim Leadbeater’s assisted suicide bill will return to the Commons for a second day of report stage proceedings – when MPs consider amendments. Third reading, when the House votes on the bill itself, is expected to take place the following Friday. Opponents of this controversial bill will be hoping that enough MPs feel uneasy about it to say ‘this far and no further’. They will need around 30 MPs to have changed their minds since a vote last year in order for a defeat of the legislation to be assured.

As politicians have weighed this issue, there’s been a conspicuous silence from one constituency you’d expect to have been outspoken: suicide prevention organisations. People might be surprised to know that Samaritans, perhaps the best-known suicide prevention charity in the UK, a cornerstone of prevention efforts since the 1950s, did not submit evidence on the bill before Westminster or a separate bill at Holyrood. Other groups like Suicide Prevention UK (SPUK) and Papyrus have also been silent. One has to wonder why, given the bearing a law change would have on their work.

Suicide prevention charities and their volunteer counsellors do incredible work. Over the years, millions of people in desperate circumstances have received life-changing support. Today, every person contacting a suicide prevention helpline is told that their life has value, and that there is hope in the bleakest of circumstances. Every caller without exception is also told not to harm themselves. But this couldn’t continue under an assisted dying law. A two-track approach would have to be devised, depending on a caller’s circumstances. A scenario helps to illustrate this point:

Caller: “I am thinking about ending my life”.

Adviser: “Please know that there is hope. I’m here to listen and I can offer support, so you don’t have to make that choice.”

Caller: “Well, I have terminal cancer you see…”

Adviser: “Oh, sorry, I need to put you through to a colleague. Your situation is a bit more, err, complex. You need to know your legal rights”.

Some proponents of assisted dying are quick to dismiss concerns about suicide prevention, arguing that assisted dying and suicide are wholly separate categories. However, this argument doesn’t hold water. Whilst campaigners use euphemistic terminology and employ Orwellian rhetoric about ‘exercising choice at the end of life’, and people ‘shortening their deaths’, it is clear that the bills they promote would permit suicide with the enablement of the state.

An assisted dying law would see doctors prescribing lethal drugs to certain patients which they can take to end their own lives. The dictionary definition of suicide — “the act of killing yourself intentionally” — has not changed. Neither has legislation giving expression to this idea. Logically and legally then, assisted dying involves suicide.

Samaritans is clear on this. A ‘policy brief’ on assisted dying published in November — the most recent statement on the issue by the organisation — begins by saying that it usually applies to terminally ill people and involves “assisting the person who is terminally ill to hasten their own death”, adding: “The act that kills them is performed by the person themselves”. Their death is a suicide, in other words.

You might assume an organisation that says, “every suicide is one too many”, whose stated aim is to see “fewer people die by suicide”, would be opposed to assisted dying - or at the very least concerned about it. However, Samaritans goes on to say that it does not “take a position on whether assisted dying is right or wrong, or on what the law should be on this matter”. Why? Because it “would involve making a range of judgements” that could compromise people’s “perception of our ability to provide non-judgemental emotional support”.

Samaritans and other suicide prevention organisations should be intensely interested in what the law says. The introduction of assisted dying in any part of the UK would mean suicides being condoned and enabled in healthcare settings for the first time — a radical departure from the existing approach. Professionals always counsel against suicide, no matter a person’s motivation for wanting to end their life. Every citizen is precious, and every life worth saving.

Prevention organisations must also realise that a change of this gravity will have a wider impact on culture. Research shows a rise in non-assisted suicides in countries that have introduced the practice. Sending a message that some suicides are permissible might make their prevention work harder. Organisations saying nothing in the face of all this is astonishing.

As noted above, assisted dying poses practical questions as well as philosophical ones. If the law changes, organisations will no longer be able to adopt a universal approach to suicide prevention. A call to a suicide prevention helpline from a terminally ill person will have to be handled differently to a call from a person who is not terminally ill. For some, suicide would be a healthcare ‘right’. How will organisations navigate this? Doesn’t it concern them?

There has been some advocacy from individuals engaged in suicide prevention, if not from organisations. In February 2024 psychiatrists wrote to The Times to warn that the Westminster assisted dying Bill would “undermine daily efforts to prevent suicide”, particularly among the elderly. Louis Appleby, the UK Government’s suicide prevention adviser has also spoken against a change in the law, arguing that it would harm efforts to drive down suicides.

Appleby explained, “once the principle behind suicide prevention has been set aside, once any part of the ground has been ceded — not only to allow suicide but to assist it — we have lost something we may not get back. There are countless causes of irremediable hardship, many reasons people may want to make despairing choices. Could they become exceptions to suicide prevention too?” This principled position is exactly what you’d expect from someone whose job is protecting hurting people, no matter their personal situations.

I’m loath to criticise suicide prevention groups as I deeply appreciate their work. However, by not contributing to the debate on assisted dying, they are abdicating their responsibility to shape a policy that would impact their mission, and the people they serve. A policy that would lead to state-sanctioned suicides and impact culture in profound ways. It’s terribly sad to see groups that fight to end suicides failing to stand against a policy that would harm their work. Failure to speak today may be viewed as a dereliction of duty in years to come.

With a final vote on Kim Leadbeater’s Bill days away, and the decisive vote on Scottish plans not due for months, there is still time for suicide prevention groups to enter the fray. I pray that they will.

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