Dealing with death at Christmas

On the darkest December day, a grim anniversary is recalled.

Jean Kabasomi

Jean is a consultant working with financial and Christian organisations. She also writes and broadcasts.

A moody sky overshadows a shingle beach on which a lone empty deckchair stands. A pier with funfair is in the middle distance.

Brighton Pier.

Nick Fewings, via Unsplash.

Thursday 17th December 2020 - a day I won’t forget.

Christmas 2020 was already proving to be a little strange. The UK was in this weird place of tiered restrictions, a sort of semi-lockdown approach. In London and the southeast, we had a bit more flexibility than folks in the north of the country, but people were not really out and about. Most people were saving their interactions for Christmas Day, so the streets were mostly quiet.

Like virtually everyone working in the financial services, I was working from home. The night before, my older brother had left the house after an argument and not come home. My younger brother and sister were concerned about his whereabouts. His phone kept going to voicemail. They were worried. There wasn’t much to do or anyone to see because everyone was regulating their behaviour and saving themselves for Christmas. I, on the other hand, was more nonchalant about his ‘disappearance’. My view was that he was an adult and had a habit of doing ‘immature things’ to get our attention. I thought, ‘He would come back home when he needed to.’ Little did I know how wrong I would be.

At about 4:50pm, as I was winding up and about to log off at work, I saw a police car in our street. My room is on the second floor of our house and my desk is positioned so that I can look directly out of the window onto the street in front of our house. The police car stopped in front of our house. The officers got out and opened our gate. I remember I went downstairs and said, ‘The police are here.’, just before the doorbell rang. I was slightly annoyed, I remember thinking, ‘What silly thing has my brother done now?’

My Mum invited them in. But they wouldn’t speak to her. They were looking for my sister. This seemed really weird at the time. Mum kept asking them what they wanted. But they wouldn’t reply. They just kept saying that they needed to speak to my sister. They wouldn’t speak to my sister in front of all the family, so they led my sister outside into the garden. It was dark outside. We couldn’t hear what they were saying because the back door was shut but we could see my sister’s reaction. She was deeply distressed. My Mum was beginning to get upset too, because she could see my sister through the window. They came back into the house. The police remained silent. It was just strange. My sister kept saying that we all needed to sit down in the living room. Mum kept asking the police what was going on but they remained silent. My younger brother and I were also frustrated and wanted to know. ‘Just tell us what is happening’, I remember saying. But my sister kept saying that we needed to sit down and go to the living room.

We finally all sat down and then one of the officers began to speak. I don’t remember his exact words but it was something to the effect of ‘A body was found this morning at Brighton Pier. From the belongings found on the body, we have identified that it is the body of your brother.’

At this point, I don’t think any of us really understood what he was saying. Someone must have asked, ‘Does that mean he is dead? Are you saying he is dead?’ ‘Yes.’, was the response. ‘How did he die?’, was the next question. Again, more weirdness. It seemed that they didn’t really want to use the word suicide, but that’s what it was. We kept asking for more details. What time? How did it happen? Was there anyone with him? But nothing was forthcoming. It all felt like a cover-up. And then it was over. They left and it was just us left to process it. It all seemed so surreal.

That evening is all a bit of a blur. I am quite a practical person - I knew I was leading a bible study meeting that evening. So, I messaged, the pastor in charge to say I wouldn’t be able to lead it that night. After that, the next feeling, I remember is annoyance towards my brother. I felt it was selfish on so many different levels. Why did he have to do this? How does it solve anything? Why is he always looking for attention? Why would anyone do something like this just before Christmas? I remember feeling he had destroyed Christmas for us forever. Why didn’t he just say something to us? We had just started playing tennis on weekday mornings before I logged into work, why didn’t he mention he was upset then? My younger brother and sister were deeply disturbed and didn’t know what to say or do. Both were blaming themselves. Mum was totally shocked. I kept thinking and saying that he didn’t mean to do it. It was just a mistake that he couldn’t undo. If we weren’t in this quasi-lockdown situation, maybe someone would have noticed him in the water sooner and he would have been rescued? Maybe someone would have been walking along the Pier that night, seen him in the water, jumped in and pulled him out? We didn’t need a hero, maybe someone would have seen him in the water and just called 999? Maybe someone would have noticed him pacing up and down, and tried to speak to him before he went over the edge?

The run-up to Christmas that year was extremely difficult. The government announced a full lockdown again and my family had to travel to the morgue in Brighton to formally identify my brother. I chose not to go with them, I felt at the time, that I wasn’t ready to see my brother’s body. We also had a tree in our garden whose roots had ruptured the sewer pipe, causing our bathroom to flood. It was all one big mess.

I am in charge of the Christmas shopping operation in our house. Christmas is my favourite time of the year. I love the carols, the weather, the darkness, the cosiness, the services at church, the Christmas TV schedule, the food and the opportunity to rest, pause and reflect. I love everything about Christmas. But now it felt weird celebrating Christmas. The delivery came. On Christmas day, I cooked, my sister baked. But it was all just so sad. We sat in silence through a lot of it just eating. Sometimes we spoke about the days leading up to my brother’s death. At different points throughout the day, one or all of us would be struggling to hold back our tears or silently sob. That period was one of the most difficult periods of my life.

I do not have to be in a state of constant mourning throughout the Christmas period. Neither do I need to pretend or ignore that I haven’t experienced death at Christmas.

Three years later, Christmas is still my favourite time of the year. Why? Despite everything, I still believe in the hope that came into the world at Christmas through Jesus Christ. It is that hope that helped me pull through that time. I held on to the comforting words I found in the Bible. I found people who supported me and worked through my grief on the Bereavement Journey. On this course, I discovered that it was okay to be angry, guilty, disappointed and sad about death. It was all part of the process. It was okay to grieve differently from my siblings and my Mum. I didn’t have to force them to feel like me, nor make myself feel like they did. As we began to piece together my brother’s final days, I slowly understood that he had his own mental struggles and sadly was unable to find the help he needed.

I learnt that grief involves the whole person – the body, soul and mind. I understood why I sometimes felt exhausted and at other times I was wide awake. It all made sense when I suddenly felt sad on my way home from my first time at Wimbledon. The body has a weird way of remembering things even when you think you are okay mentally, so I wasn’t surprised when I got a severe migraine exactly three years to the day that my brother didn’t come home. My faith does not mean that I understand everything about my experience neither does it mean that I can’t lament, question or be unhappy about the way things unfolded.

For me, Christmas is still a time to celebrate the birth of Jesus Christ, the birth of Hope. But it is also a time of solemnity, even of grief. As the years go by, this will get easier but probably won’t go away. The two feelings are not mutually exclusive. I do not have to be in a state of constant mourning throughout the Christmas period. Neither do I need to pretend or ignore that I haven’t experienced death at Christmas. Rather, the most honest thing I can do is to acknowledge both feelings and take each day as it comes.

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.