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

Culture

Gaza

Israel

Politics

2 June 2025

5 min read

Politics is the only way to solve the tragedy of Gaza

Trump is not the first person to want to create a Riviera by the Mediterranean.

Graham Tomlin

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

A sign projected on to the Houses of Parliament reads: how many is too many.

A projection protest sign, London.

Christian Aid.

Whichever side you take in the Israel-Gaza conflict, the stories can't help bring a sense of desperation. Images of starving children, the fate of Jewish hostages still held in darkness - either way, this remains a place of unimaginable suffering. And meanwhile, the bombs keep dropping, people die, and Hamas retains its hold.

Among Israel’s friends, voices have been murmuring a radical solution to the problem of Gaza. Donald Trump’s plan was to raze the territory to the ground, shift 50 million tonnes of debris and displace its people to neighbouring countries to build the ‘Riviera of the Middle East’ in what had until now, been Gaza. The plan might have been met with some amusement when it was aired, but it gave permission for many within Israel to think similar thoughts.

Bezalel Smotrich, the Israeli finance minister, recently claimed that after the Israeli operation, “Gaza will be entirely destroyed” and its Palestinian population will “leave in great numbers to third countries.” Many within Israel seem to think the stubborn, Hamas-ridden enemy living next door needs to be eradicated. To a population weary of decades of conflict, fearing that there will never be peace while Hamas remains in Gaza, and aware of how difficult it is to winkle out the Islamic terrorist group while the Palestinian population remains there, you can understand the attraction of this radical solution.

However, the Israelis might have good reason to be cautious. And that is not a counsel from their opponents - but from their own history.

In the early 130s AD, the boot was on the other foot. It was the mighty Gentile Roman Empire that ruled over the same patch of land, which they were soon to call Palestina. Jews were a minority, but they still harked back to their long roots in the land, the days of Joshua and King David, and even more recently to the Jewish Hasmonean kingdom 200 years before - the last time before the modern state of Israel that Jews were in control of the land.

The emperor at the time, Hadrian, passed through Jerusalem in 130 AD, along with his entourage and his lover, the young slave boy Antinous. He started to paganise the city, erecting statues of gods and emperors, even of his young favourite, all of them offensive to Jewish sensibilities. The smouldering resentment soon erupted with a revolt led by a fierce and determined Jewish fighter, Bar Kokhba. This was the second Jewish uprising after the earlier one in the 60s that had led to the destruction of the great Jewish Temple in Jerusalem by Titus, under the reign of the emperor Vespasian in 70 AD. For the Romans, one revolt might just be tolerated, two was too much.

Hadrian came to the same conclusion as Bezalel Smotrich – a rebellious territory had to be erased from the map, although this time, it was Jerusalem that was to be eliminated, not Gaza. Its Jewish population was to be scattered, its name deleted, and memories of past glories buried for good.

And so, in 135 AD, the bulldozers moved in. Jerusalem was effectively flattened, and a Roman city built on its ruins. Aelia Capitolina was its new name, a smaller city, yet decadently built around the worship of Greek and Roman gods, with splendid gates, pagan Temples, a classic Roman Forum, expansive columned streets – not quite the Riviera of the middle east, but maybe the Las Vegas. ‘Jerusalem’ was scrubbed from the map.

At the centre of the sacred Jewish Temple Mount, Hadrian erected a statue of himself. He deliberately planted a statue of Aphrodite over the very spot where the early Christians insisted that the death and resurrection of Jesus had taken place – where the Church of the Holy Sepulchre stands today. Circumcision was outlawed, many Jews were killed, and those remaining were banned from the city, dispersed anywhere where they could find shelter. In fact, the map of the Old City of Jerusalem today is still marked by this design, with the two main Hadrianic streets diverging south from the Damascus Gate, with archaeological remains of the Roman city still visible for visitors.

Yet of course it didn’t work. No-one calls it Aelia today. People's attachment to land goes deep. The Jews could not forget their roots in this patch of the earth's surface. As Simon Sebag Montefiore put it: “the Jewish longing for Jerusalem never faltered”, praying three times a day throughout the following centuries: “may it be your will that the temple be rebuilt soon in our days.”

Palestinian attachment to land is similarly strong. Nearly 80 years after the creation of the state of Israel in 1948, families still cling on to the keys to homes that were taken from them during that traumatic period. Like the Jewish yearning for Jerusalem, they too, like people across the world, have a deep attachment to ancestral lands, which go back to the ‘Arabs’ mentioned in the book of Acts, to whom St Peter preached in the early days of the Christian church.

Executive decisions by distant rulers such as the emperor Hadrian or President Trump might seem like neat solutions to intractable problems. But they seldom work in the long term.

The famous biblical injunction ‘an eye for an eye, a tooth for a tooth’ was meant not as an encouragement to violence but the exact reverse. It was mean to set a limit to the development of blood feuds, which could, out of anger and trauma, so easily lead to disproportionate reaction and never-ending vendettas. When St Paul wrote “Beloved, never avenge yourselves, but leave room for the wrath of God; for it is written, ‘Vengeance is mine, I will repay, says the Lord’”, he was recalling an ancient piece of Jewish wisdom that set limits on human capacity to sort out intractable problems by violence. He knew a better way: “Do not be overcome by evil, but overcome evil with good.”

Luke Bretherton, Regius Professor of Moral Theology at Oxford and a Seen & Unseen writer, argues that there are really only four ways you can deal with neighbours who prove difficult: you can try to control them, cause them to flee, you can kill them, or you can do politics – in other words, try to negotiate some form of common life, as ultimately happened in Northern Ireland, South Africa, and so many places of long-standing conflict.

Politics, the business of learning how to live together across difference, is messy, complicated and hard work. Especially so when there are deep hurts from the past. Yet, as the failure of Hadrian’s radical solution shows, there is no real alternative in the long term.

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