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

Comment

Economics

Leading

Politics

Wisdom

8 May 2025

5 min read

When someone makes a claim, ask yourself these questions

How stories, statistics, and studies exploit our biases.

Alex Edmans

Alex is a professor of finance, and an expert in the use and misuse of data and evidence.

A member of an audience makes a point while gesturing.

On the other hand...

Antenna on Unsplash.

“Check the facts.”

“Examine the evidence.”

“Correlation is not causation.”

We’ve heard these phrases enough times that they should be in our DNA. If true, misinformation would never get out of the starting block. But countless examples abound of misinformation spreading like wildfire.

This is because our internal, often subconscious, biases cause us to accept incorrect statements at face value. Nobel Laureate Daniel Kahneman refers to our rational, slow thought process – which has mastered the above three phrases – as System 2, and our impulsive, fast thought process – distorted by our biases – as System 1. In the cold light of day, we know that we shouldn’t take claims at face value, but when our System 1 is in overdrive, the red mist of anger clouds our vision.

Confirmation bias

One culprit is confirmation bias – the temptation to accept evidence uncritically if it confirms what we’d like to be true, and to reject a claim out of hand if it clashes with our worldview. Importantly, these biases can be subtle; they’re not limited to topics such as immigration or gun control where emotions run high. It’s widely claimed that breastfeeding increases child IQ, even though correlation is not causation because parental factors drive both. But, because many of us would trust natural breastmilk over the artificial formula of a giant corporation, we lap this claim up.

Confirmation bias is hard to shake. In a study, three neuroscientists took students with liberal political views and hooked them up to a functional magnetic resonance imaging scanner. The researchers read out statements the participants previously said they agreed with, then gave contradictory evidence and measured the students’ brain activity. There was no effect when non-political claims were challenged, but countering political positions triggered their amygdala. That’s the same part of the brain that’s activated when a tiger attacks you, inducing a ‘fight-or-flight’ response. The amygdala drives our System 1, and drowns out the prefrontal cortex which operates our System 2.

Confirmation bias looms large for issues where we have a pre-existing opinion. But for many topics, we have no prior view. If there’s nothing to confirm, there’s no confirmation bias, so we’d hope we can approach these issues with a clear head.

Black-and-white thinking

Unfortunately, another bias can kick in: black-and-white thinking. This bias means that we view the world in binary terms. Something is either always good or always bad, with no shades of grey.

To pen a bestseller, Atkins didn’t need to be right. He just needed to be extreme.

The bestselling weight-loss book in history, Dr Atkins’ New Diet Revolution, benefited from this bias. Before Atkins, people may not have had strong views on whether carbs were good or bad. But as long as they think it has to be one or the other, with no middle ground, they’ll latch onto a one-way recommendation. That’s what the Atkins diet did. It had one rule: Avoid all carbs. Not just refined sugar, not just simple carbs, but all carbs. You can decide whether to eat something by looking at the “Carbohydrate” line on the nutrition label, without worrying whether the carbs are complex or simple, natural or processed. This simple rule played into black-and-white thinking and made it easy to follow.

To pen a bestseller, Atkins didn’t need to be right. He just needed to be extreme.

Overcoming Our biases

So, what do we do about it? The first step is to recognize our own biases. If a statement sparks our emotions and we’re raring to share or trash it, or if it’s extreme and gives a one-size-fit-all prescription, we need to proceed with caution.

The second step is to ask questions, particularly if it’s a claim we’re eager to accept. One is to “consider the opposite”. If a study had reached the opposite conclusion, what holes would you poke in it? Then, ask yourself whether these concerns still apply even though it gives you the results you want.

Take the plethora of studies claiming that sustainability improves company performance. What if a paper had found that sustainability worsens performance? Sustainability supporters would throw up a host of objections. First, how did the researchers actually measure sustainability? Was it a company’s sustainability claims rather than its actual delivery? Second, how large a sample did they analyse? If it was a handful of firms over just one year, the underperformance could be due to randomness; there’s not enough data to draw strong conclusions. Third, is it causation or just correlation? Perhaps high sustainability doesn’t cause low performance, but something else, such as heavy regulation, drives both. Now that you’ve opened your eyes to potential problems, ask yourselves if they plague the study you’re eager to trumpet.

A second question is to “consider the authors”. Think about who wrote the study and what their incentives are to make the claim that they did. Many reports are produced by organizations whose goal is advocacy rather than scientific inquiry. Ask “would the authors have published the paper if it had found the opposite result?” — if not, they may have cherry-picked their data or methodology.

In addition to bias, another key attribute is the authors’ expertise in conducting scientific research. Leading CEOs and investors have substantial experience, and there’s nobody more qualified to write an account of the companies they’ve run or the investments they’ve made. However, some move beyond telling war stories to proclaiming a universal set of rules for success – but without scientific research we don’t know whether these principles work in general. A simple question is “If the same study was written by the same authors, with the same credentials, but found the opposite results, would you still believe it?”

Today, anyone can make a claim, start a conspiracy theory or post a statistic. If people want it to be true it will go viral. But we have the tools to combat it. We know how to show discernment, ask questions and conduct due diligence if we don’t like a finding. The trick is to tame our biases and exercise the same scrutiny when we see something we’re raring to accept.

This article is adapted from May Contain Lies: How Stories, Statistics, and Studies Exploit Our Biases – and What We Can Do About It
(Penguin Random House, 2024)
Reproduced by kind permission of the author.

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