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

Football

Justice

29 July 2025

5 min read

The 50-year injustice at the heart of women’s football

Now we need to do these two things to put right decades of disparity

Jonathan Rowlands

Jonathan is a theology lecturer and Liverpool FC fan.

A victorious women's football team celeberate.

It came home.

The Football Association.

I don’t normally like men’s international football. I spend all season wishing Bukayo Saka and Jordan Pickford nothing but misfortune and now, suddenly, I’m expected to cheer them on? Not for me, thanks. I’ll stick to revelling in scouse Schadenfreude when football, inevitably, does not come home.

By contrast, I find the Lionesses much easier to support. That’s probably because, to my shame, I don’t really follow the Women’s Super League as much as I should. I don’t watch them with any petty grudges lingering in my mind. It does mean, however, that I can happily join the 12.2 million other people tuning in to watch Chloe Kelly hop, skip, and volley England to another European Championship.

It also helps that they seem to keep winning in the most implausible ways possible. There’s a stat going round social media at the moment that, across all the knock-out games of this Euros, England were only ahead for 4 minutes and 52 seconds. Incredible.

The Lionesses have – yet again – managed to show their nation the joy and drama of football and look set to inspire yet more women and girls to get involved in grass roots football. Women’s football, it would seem, is in rude health. But, look beneath the surface a little, and there are still significant disparities between the women’s game and the men’s game.

In May, Chelsea effectively sold their women’s team to themselves: they sold the team to BlueCo (Chelsea’s parent company) for a reported £198.7m. This is not the first time Chelsea have engaged creative accounting. In April. 2024, the club revealed it had sold two hotels it owned to one of BlueCo’s sister companies (a move later upheld by the Premier League itself). A whole women’s football team – a good one, at that! – being leveraged for accounting purposes.

Elsewhere, Liverpool Women’s Team sold their star player – Canadian forward Olivia Smith – to Arsenal for a world record fee of … £1m. To put that into context, Liverpool’s men’s team have already bought Florian Wirtz for roughly £116m this summer. They may add to that by buying Alexander Isak for anywhere up to £150m. And that’s to ignore the purchases Hugo Ekitike (£69m), Milos Kerkez (£40.8m), or Jeremie Frimpong (£35m). Moreover, the first male player to be sold by an English club was Trevor Francis, sold by Birmingham City to Nottingham Forrest. The year? 1979. 46 years ago.

In purely financial terms, then, the women’s game seems to be about 50 years behind the men’s. And yet, there are the Lionesses. They have just retained the European Championship. They have made three finals in a row, winning the Euros twice and narrowly losing the World Cup final in 2023. By contrast, the men’s team famously haven’t won a major trophy since 1966.

And so why does women’s football exist in an alternative financial universe about 50 years behind the men’s game? Well, I think a big part of it is making up for lost time.

The FA banned women from playing at FA-affiliated grounds between 1921 and 1971. Did you know that? It’s one of the UK’s greatest sporting shames and yet it’s hardly common knowledge. How like this country to front up to its institutional mistakes with silence.

For 50 years women were effectively unable to participate in the sport in any meaningful and professional way. 50 years. Where have we heard that number before?

Prior to this, women’s football had been rather popular. Dick, Kerr Ladies FC regularly attracted matchday audiences of thousands. In 1920, the year before the FA ban, 53,000 fans went to Goodison Park to watch they play against St. Helens. For context, this is a crowd so big the vast majority of Premier League stadiums would not be able to accommodate it. It would fill Brentford’s stadium three times over, and there would still be people queuing up outside.

For 50 years, men’s football was able to accelerate and grow while women’s football matches simply weren’t possible. Who knows where women’s football would be now, if it had been allowed to continue with the successes it had won for itself.

The success of the men’s game is built, in part, upon the enforced stagnation of the women’s game. People watched men’s football because it was the only football it was possible to watch. Men’s football owes its success in part to this. I don’t see how we can say otherwise. In response to this, I wonder if there are two things the sport might do to attempt to rectify this somewhat: one big, one small.

First, the big change. I wonder if there does need to be some form of reparations instituted to restore parity and to right the wrongs of the past? I know this won’t be popular. I love football, and I love it when my football club spends loads of money on players. I love that Liverpool (men’s team) might spend over £100m on two separate players this summer. I probably shouldn't be rubbing my hands at this, but if I’m honest, I am.

But at least some of this money ought to be diverted away from the men’s game and funnelled towards the women’s game. If men’s football is built in no small part on the enforced cessation of women’s football, then this seems only to be right. It’s not about punishing men’s football or paying a penalty for wrongdoing. It’s simply about restoring back to women’s football that which rightfully belongs to it.

Second, the small change. We should start calling men’s football teams ‘Men’s Football Teams’. When I talk about Liverpool Men’s Team, I just say ‘Liverpool’. I know, and anyone listening to me knows, that I mean the men’s team. I then add ‘Women’s’ when I’m talking about the Women’s Team.

The effect of this is that the ‘Men’s Team’ becomes the ‘default’ way of thinking about football. It is the ‘normal’ way of engaging with the sport, and this is then qualified or relativised by my talking about ‘Women’s football’ elsewhere. ‘Women’s Football’ becomes a smaller sub-category of the bigger category of ‘football’ as a whole, which is implicitly linked to ‘Men’s football’ specifically.

By taking the time to specify ‘Men’s Football’, we remind one another that football needn’t be played by men at all. That it, too, is just one way in which the sport might be engaged with or played. Not the ‘default’ or ‘correct’ way the sport exists. It’s a small change that, with time, may have a big effect on the way the sport as a whole of perceived.

50 years of injustice cannot be repaired overnight. There is a lot of work to be done to undo the wrongs of football’s historic treatment of women. But the sooner men’s football starts, the sooner justice will be restored.

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