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

Creed

Nationalism

Politics

27 May 2025

6 min read

Love is not an executive order: what Christian Nationalism gets wrong

Fear has never been a motivator of wise, just, and righteous action.

Barnabas Aspray

Barnabas Aspray is Assistant Professor of Systematic Theology at St Mary’s Seminary and University.

A protester wearing a Union Jack flag and hat and holding a cross, points while a man looks on.

Far right protesters, Portsmouth.

Tim Sheerman-Chase, CC BY 2.0, via Wikimedia Commons

The term “Christian nationalism” means different things to different people. John Stackhouse defines nationalism as “love of one’s nation, identification with it, and special concern for its well-being” and sees nothing wrong with it from a Christian point of view. But this is not the normal way the term is used today. Rather, it means an ideology that seeks political power in order to merge Christian identity with national identity. In other words, it means Christians seeking to impose Christian values on all citizens of a nation by the force of law.

That’s not as bad as it may sound at first glance. Everyone thinks some values should be imposed for society to function – for example, human rights, private property, democracy. In one sense, there’s nothing unusual about Christians wanting their values to become law. Everyone – Muslim, Secular, pluralist – wants the law to reflect their values. How could anyone have values and not want their nation’s laws and policies to reflect them?

But for Christians, there’s a catch. “Christian values” include not forcing people to live Christian lifestyles who do not identify as Christian. Christian values are founded on the teaching and example of Jesus, and he was never coercive. He aimed at people’s hearts, seeking willing rather than coerced obedience. His goal was that people should follow him and live by his teachings because they wanted to more than anything else in the world, not because they would be imprisoned or disadvantaged if they don’t. The gospel is an invitation to the most rewarding and fulfilling life imaginable, not an executive order to be obeyed out of fear.

Jesus explicitly taught that Christian politics should be different to anything else the world has ever seen:

“The rulers of the nations lord it over them, and their high officials exercise authority over them. Not so with you. Instead, whoever wants to become great among you must be your servant.”

With these words (recorded in the gospel of Matthew), Jesus set a political agenda for his followers radically different to that of every other movement, religion, institution, or nation. Where others have always used power to dominate, control, and coerce obedience, Christians are to use power to serve those under them and to pursue their flourishing. With his own life Jesus showed what this looks like. The Jews expected the messiah to be a great military leader who would rally an army under his banner, shake off the Roman oppression, establish Israel as a nation, and rule it with absolute power and authority. Instead, rather than commit any violence, he submitted to death at the hands of the Roman oppressors.

Jesus did not mean that his followers should not seek power and influence in the world, or that they should lie down and let themselves be trampled on like a doormat. The “Christian difference” is not to be non-political, withdrawn from all engagement in worldly affairs as if God did not care what happens in the world. No: the Christian difference is twofold: (1) never to seize or maintain power through violence, coercion, lies, manipulation, or any means that supposedly justifies the ends, and (2) to use power (when we are freely and willingly given it) in service to everyone regardless of their belief or lifestyle, especially the powerless.

A truly “Christian” nation would never try to coerce Christian behaviour from anyone.

Christians have not always done politics this way. In the centuries since Jesus walked the earth, they have often succumbed to the temptation to do politics like the rest of the world: grasping at authority and holding onto it by any means necessary, using it to benefit ourselves and our agenda in ways that harm and oppress others. The treatment of Jews in the late medieval period is a sobering example. Jews were forced to live in ghettos and wear conical hats. They were forbidden to hold public office, to build synagogues higher than any church, or to walk in the street on Sundays. Eventually they were forcibly expelled from several European states in order to leave no impediment to the fashioning of a truly “Christian nation,” i.e., a nation with only Christians living in it.

Today, many Christians in Western nations are engaging in efforts to fight back against world views they believe are encroaching on them – secularism, Islam, and liberalism. They want to reassert Christianity as the dominant cultural force. It seems to me that these efforts are largely motivated by fear, brought about by the decline of Christian influence. There is a strong urge to self-preservation when one feels oneself increasingly marginalized. They feel that if they don’t regain power, then all the values and lifestyle that held dear will be swept away. They must protect themselves and seek to preserve Christian values by whatever means available. They must take back control, using financial, political, and cultural capital to regain governance and re-establish Christian laws in ‘our land’.

Yet fear has never been a motivator of wise, just, and righteous action. Fear draws our attention away from the poor and needy towards our own plight. Fear makes us strike back with a self-protective instinct. When we are afraid, we feel justified in putting our own needs and priorities first. Violent behaviour is labelled “self-defence,” cutting aid budgets is labelled prudence, and refusing admission to refugees who have lost everything and are fleeing persecution is seen as the only sane course of action in a world of finite resources. Fear drives us to seek our own advantage, something Jesus never did. Perhaps Jesus knew that fear can be the greatest force to prevent us from living a Christlike life of service. Perhaps it’s not a coincidence that “do not be afraid” is the most frequent command in the Bible.

For Christians, like me, there are better motivators for political action: things like wisdom, justice, and peace. (Dare I say love? Or is that too controversial?) But the best motivation of all is the desire to follow Jesus’ teachings and example not only once we have obtained power, but in how we seek it and how we hold onto it.

There’s nothing intrinsically wrong with the idea of a “Christian” nation, if that means a nation that acts towards people – both citizens and non-citizens – the way Jesus did (and supposing the nation was not constituted by violence in the first place – but that is another story). A truly “Christian” nation would never try to coerce Christian behaviour from anyone. It would respect people’s freedom to live and believe what they chose, and would give equal opportunities, equal benefits, and equal rights to Christians, Muslims, atheists, and Jews alike. It would use its power to serve all people, especially the most vulnerable and least able to look after themselves. It would welcome and protect any foreigner who fled there to save their life or freedom, having lost everything at home.

Such a nation would not be characterised by fear of losing its power. It would not seek to preserve its influence by blocking non-Christians from citizenship or positions of government. If the tide turned against it, it would humbly relinquish power rather than do anything coercive to hold on to it, just as Jesus humbly went to the cross rather than use violence against his oppressors.

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