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

Community

Migration

Politics

20 May 2025

5 min read

Starmer’s ‘island of strangers’ rhetoric is risky and wrong

The Prime Minister needs an English lesson.

Krish Kandiah

Krish is a social entrepreneur partnering across civil society, faith communities, government and philanthropy. He founded The Sanctuary Foundation.

A prime minister stands next to an Albanian police officer in front of a ferry.

Border control. Starmer in Albania.

X.com/10DowningSt.

In a recent speech launching the UK government’s white paper on immigration, Prime Minister Keir Starmer expressed concern that the country risks becoming an “island of strangers.” It is a compelling phrase - yet, for many, a deeply worrying one. Some argue it echoes Enoch Powell’s notorious 1968 “Rivers of Blood” speech, in which the then Conservative MP for Wolverhampton claimed that people in the UK were being “made strangers in their own country”. Even if the reference was unintentional, the sentiment is divisive and dangerous. Here are five reasons why this narrative must be challenged.

Geography: We are fundamentally connected

First and foremost, the United Kingdom is not a single island. To describe it as such is not only geographically inaccurate but symbolically unhelpful and politically careless. This sort of language risks excluding all those UK citizens who live in the other 6,000 islands that make up our country - islands such as the Isle of Wight, Anglesey, the Hebrides, Orkney, Shetland and the Channel Islands, as well as the 2 million UK citizens who live in Northern Ireland. Many of our families, mine included, are testament to the fact that between the British Isles there are connections and marriages. We are islands, plural, united by a national bond of friendship and collaboration, and a shared story of connection across water.

Sociology: We are intrinsically social

The notion that the UK is becoming “an island of strangers” contradicts what we know about how human societies function. We are fundamentally relational - forming and building connections in our schools, workplaces, neighbourhoods, shops, and clubs on a daily basis. Even if we do not know the names of those who live across the street, we have a great deal in common. They are not strangers, but neighbours. In times of crisis, as shown during the Covid pandemic, neighbourliness is a critical front-line defence. To undermine that by calling our neighbours ‘strangers’ is a recipe for social breakdown. True social cohesion can never come through exclusion only by being deliberately nurtured through acts of welcome, the language of inclusion and recognition of shared purpose and identity.

Language: What we say matters

In his speech, the Prime Minister gave credence to the claim that migrants fail to integrate because they don’t speak English. He said: “when people come to our country, they should also commit to integration, to learning our language.” But English proficiency is not the main barrier to social cohesion. As a country that proudly recognises multiple languages: Welsh, Scottish Gaelic, Irish, Cornish, British Sign Language, we should understand this. And as a nation who fails miserably at learning other world languages we should appreciate the enormous effort it takes to learn any level of English. The vast majority of migrants put us to shame in how quickly and readily they learn to communicate effectively. Might I suggest that the Prime Minister - whose speech contained questionable language that was factually untrue, politically dangerous and socially offensive - might benefit from an English lesson himself?

Honesty: We benefit from migration

When the Prime Minister claimed he was launching a strategy to “close the book on a squalid chapter for our politics, our economy, and our country,” he implied that migration is to blame for many of the difficulties the UK is facing. This is not a new tactic — some of the world’s darkest moments have been preceded by politicians stoking fear and resentment against immigrants for political gain. We must resist this rhetoric. Perhaps we could start by asking exactly which migrants are being blamed for this so-called "squalid chapter"? Is it the 200,000 people from Hong Kong who have arrived under the British National Overseas scheme, bringing skills and making major contributions to our economy? Or the 250,000 Ukrainian refugees who have been welcomed with open arms and helped knit communities closer together? Is it the 30,000 Afghans who supported British forces, risking their lives to do so? Or the 750,000 international students contributing £35 billion a year to the UK economy, sustaining our universities and global reputation for outstanding education and research? What about the 265,000 non-British NHS staff who work tirelessly to care for our sick and elderly? Blaming migrants for the UK’s problems is dishonest and dangerously divisive, potentially alienating the very people who are often most invested in making the country stronger, safer, and more successful.

Integrity: We need to fix the real problem

The Prime Minister’s use of the phrase “island of strangers” strikes a chord, not because we are all strangers to one another - we are not - but because many of us increasingly feel isolated in our own communities. There is evidence to support this emotional response. According to the Office for National Statistics, around 27% of adults in the UK report feeling lonely always, often, or some of the time. A report titled A Divided Kingdom, published just a day after the government’s immigration white paper, highlights growing intergenerational divides with only 5.5 per cent of children in the UK living near someone aged 65 or older, and just seven per cent of care home residents regularly interacting with anyone under the age of 30. Young adults are increasingly working remotely, reducing opportunities for casual, everyday social contact. Rising numbers of people live alone, and digital technology — while connecting us in some ways — often replaces the richness of face-to-face relationships.

These shifts are not caused by immigration, and blaming migrants for the disconnections and discontent we feel only distracts us from addressing the real causes of social fragmentation. We need to find ways to reconnect with one another in person, recognising in those around us the image of God, our common humanity and the opportunity for service.

Starmer’s narrative must be challenged before it becomes a self-fulfilling prophecy. The great English poet and cleric John Donne famously wrote:

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main.”

It would be sad if, in our modern world, we lost sight of that truth and ended up becoming estranged islanders floating on a sea of fear and xenophobia.

Celebrate our 2nd birthday!

Since Spring 2023, our readers have enjoyed over 1,000 articles. All for free.
This is made possible through the generosity of our amazing community of supporters.

If you enjoy Seen & Unseen, would you consider making a gift towards our work?

Do so by joining Behind The Seen. Alongside other benefits, you’ll receive an extra fortnightly email from me sharing my reading and reflections on the ideas that are shaping our times.

Graham Tomlin
Editor-in-Chief

Join with us