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

Climate

Comment

Sustainability

6 May 2025

5 min read

What “drill baby drill” really means for the world’s poor

Climate jargon pales in comparison to hard, hot and harsh realities.

Jane Cacouris

Jane Cacouris is a writer and consultant working in international development on environment, poverty and livelihood issues.

Forest in Cameroon.

Edouard Tamba on Unsplash.

“Drill, baby, drill,” declared Donald Trump during his inauguration speech in January to roars of Republican approval, going on to sign executive orders to “unleash” the American oil and gas industry to do just that: drill. This, even though the United States is already the largest crude oil producer of any other nation, according to its own Energy Information Administration, and has been for the past six years in a row.

Fossil fuel combustion is undeniably the largest source of greenhouse gas emissions worldwide says the IPCC, with oil accounting for about 34 per cent of global CO2 emissions from fossil fuels. And World Economic Forum statistics show that the lowest income countries produce only one-tenth of emissions but are the most heavily impacted by climate change.

Something doesn’t seem very fair here.

Many of us are aware of the statistics and policies and rhetoric around climate change. It is all buzzing around in the background of our lives, in the news, on social media and in opinion pieces like this one. But if we’re honest, it is all still theory for most of us living in the Global North.

On a recent work assignment, involving research in remote communities in Southern Cameroon, I found the true extent of climate crisis is hard hitting and very real. According to the IMF, Cameroon is ranked 16th in the world in terms of countries most vulnerable to the impacts of climate change, partly due to its geographical location.

High levels of rural poverty and the country’s economic dependence on agriculture, which employs over 70 per cent of the population adds to this climate vulnerability. But the government statistics and climate jargon, worrying as it is, paled as I discovered the reality of rural Cameroonians’ lives. Lives that depend almost solely on the productivity of the land, and therefore on the weather. Lives that have no Plan B when the climate is unpredictable.

The communities we studied live in rural villages many kilometres from any urban centre, and rely entirely on natural resources for their livelihoods. They depend on traditional rain-fed agriculture, hunting for bush meat, and collecting non-timber forest products such as tropical fruits, insects, medicinal plants, herbs and honey from the dense forests near their dwellings to survive.

The effects of the changing climate have been felt by them for some time. During periods of water scarcity, which is becoming more unpredictable and prolonged, local streams dry up, meaning crop yields fail, such as corn, groundnuts and cassava, and families go hungry. Fishing yields dwindle. The work burden for women rises, as they have to travel further to collect water for drinking, washing and cooking. Poor roads with inaccessible tracks during heavy rain events, or non-existent roads, prevent communities from accessing markets, health care and external support, making them isolated and more vulnerable to climate impacts.

With the science predicting rising future temperatures and higher seasonal variability in their region, these communities will only become more vulnerable, mirroring the story of millions of other people around the world. They must adapt to survive. The alternative is not surviving. Devastatingly, this is a very possible future outcome.

I’d say the UK is standing on the side lines in the playground, looking on.

Why should wealthy, powerful nations mostly responsible for global carbon emissions, not only refuse to compensate those at the receiving end of resulting climate change, but actively seek to cause more damage? It echoes of a bully in a school playground, inflicting suffering on a smaller child, gaining in popularity, power and self-confidence as a few egg them on, others stand by, whilst the receiver of the abuse summons all their remaining strength simply to survive and make it through another day.

So where does the United Kingdom stand in the playground?

In terms of domestic climate policy, the UK must meet net zero by 2050, in line with the target set out in UK legislation, i.e. in twenty-five years from now, total greenhouse gas (GHG) territorial emissions must be equal to the emissions removed from the atmosphere. On paper, it seems the UK is on track to achieve this. GHG emissions have halved since 1990, driven by investing in renewable power and phasing out coal in the electricity sector. However, as WWF and others have pointed out, this figure has a glaring omission. Products including clothing, processed foods and electronics imported into the UK are counted as the “manufacturing country’s emissions,” not the UK’s. This is known as “offshoring.” And according to WWF, between 1990 and 2016, emissions within the UK’s borders reduced by 41 per cent, but the consumption-based carbon footprint only declined by 15 per cent, mainly due to goods and services coming from abroad.

In terms of climate finance for the world’s poorest nations, the UK pledged to spend £11.6 billion between 2021 and 2026, and the government recently said it remains committed to meet this pledge. However, the pot from which this climate finance must come, the UK’s overseas aid budget, was slashed in recent months from 0.5 per cent to 0.3 per cent of national income to prioritise defence spending. Meanwhile, climate experts and charities are warning that what the world needs now is stronger global solidarity in the face of the climate crisis, rather than national self-interest. I’d say the UK is standing on the side lines in the playground, looking on.

Trump professes to be a practicing Christian… I wonder what would Jesus have to say about the way America and other wealthy nations have dealt with the climate crisis? One of Jesus’ most well-known and powerful teachings was to love your neighbour. The parable of the Good Samaritan in the Bible demonstrates the way we should treat our neighbours; acting with love, compassion and mercy, not only towards those we know or who live in our friendship network, community or country, but towards every human being, regardless of nationality, background or social group. In the context of climate change, Christians are called to love our global neighbours. This includes supporting the world’s poorest communities to thrive, speaking up on their behalf, demonstrating love through political and social action. Jesus certainly doesn’t teach us to put ourselves “first.”

Imagine a world where every nation signed up to Jesus’ teaching on how to treat our neighbours. Would climate change abruptly halt, human suffering stop and global peace prevail? In truth, probably not, because humanity is imperfect and we get things wrong even when we mean well. But if the intention was there, and if world leaders looked to Jesus’ lead on this, there is little doubt we would be many steps closer.

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 now