Article
Comment
War & peace
6 min read

How Ukraine reckons with its reality

From Kyiv's coffee shops to the front line.
A woman squats and touches a war memorial
War memorial in Bucha.

How on earth it came up I have no idea, but I vividly remember chatting with my grandmother about the ‘Phoney War’ of 1939. I can’t have been much older than 10. It’s not that I was especially inquisitive about history, nor that I had the presence of mind to ask for stories from her extraordinary life. How I wish I’d done that with all four of my grandparents. But my hunch is that it was prompted by sitting in the garden on a glorious summer’s day. We were probably shelling peas or peeling potatoes or something—she always got people staying to do jobs. 

She was reminiscing about how weird those months in mid-1939 were, in particular remembering how lovely the summer had been, far brighter and drier than normal. Even after the Nazi invasion of Poland on 1st September (thus triggering Britain and France to declare war two days later), the weather remained good. A sense of war’s inevitability had hovered throughout 1939, so even after Chamberlain’s famous ‘final note’ was rejected, nothing much changed. At least, not for ordinary Britons. Life went on. It would take many months before the conflict came all too close to home. 

I couldn’t help but think about this during my visit to Kyiv and Lviv earlier this month. The difference, of course, is that there was nothing phoney about Russia’s 2022 invasion or the horrors inflicted on eastern Ukraine since the 2014 annexation of Crimea. But for the majority, routines continued uninterrupted. As they must.  

For example, assuming the worst, I had contacted several Ukrainian friends offering to bring any scarce or unavailable items from Britain. No one took me up on it; it was unnecessary, they all said. After wandering through both cities, it was obvious why. Although trade will undoubtedly have been slower than before the war, shops seemed well stocked with all the necessities and not a few luxuries.  

Then on my final morning, I was quietly sipping a cappuccino in Lviv’s historic Rynok Square when the air-raid sirens suddenly cranked up into their now familiar whine. Being kept awake by Kyiv’s sirens had been a new experience for me (a mark of our Western privilege that we have avoided all-out war on our soil for decades). But this was my first daytime alert. It was even accompanied by booming Ukrainian announcements, although the advice was inevitably lost on me. As it was on all around me, who seemed assiduously to ignore it. The few mid-morning pedestrians—few tourists come here— maintained their ambling pace unchanged; the taciturn waiter patiently took orders at the next table; a middle-aged businessman on the square continued his negotiations on the phone while gesticulating with his briefcase. So naturally, I kept sipping. 

This was not because the sirens cried wolf. Just 10 days before my visit, Lviv had suffered one of the worst air attacks of the war, with 7 killed, over 60 injured, as well as the destruction of schools and historic buildings. Moreover, I met a friend for lunch an hour later who told me that some man-sized drones had attacked his side of Lviv and he saw one or two shot down. So it was all real enough. What was everyone thinking? 

Those who keep going amid a siren’s whine are not perhaps ignoring it but taking calculated risks in their perseverance.

Ignoring reality 

T. S. Eliot famously observed that "Humankind cannot bear very much reality." So perhaps that was what was going on here. After two and a half years of war, I can quite imagine exhaustion and resignation to what was going on. So it just gets ignored. Ordinary life must go on. After all, only a small proportion of the population is actively engaged in the war; the rest, if they haven’t already left, must try to keep calm and carry on. In fact, men aged between 18-60 are unable to leave at all without the necessary papers and these are hard to come by. Perhaps the only way, then, is to avoid thinking altogether. On a beautiful day, once autumn has begun to temper Ukraine’s oppressive summer heat, sustaining the illusion is simple. Life carries on. 

Of course, it can’t last. Every single person I spoke to had family or friends at the front; some had already been killed. The destruction caused by air raids brought a distant conflict onto people’s doorsteps. However, it was driving through the pleasant Kyiv suburbs of Bucha and Irpin, both of which I had previously visited several times, that reinforced the impossibility of ignoring reality. Bucha is now emblematic of the invasions very worst atrocities, from when Russian forces had Kyiv almost entirely surrounded before being pushed east. Locals were rounded up and slaughtered, with the bodies of several hundred civilians later found to have died from bullet wounds rather than shrapnel. But as we drove through, it was impossible to conceive of those horrors. Apart from anything, the weather was so lovely. Atrocities don’t occur on beautiful days… or in lovely places… surely? 

Persevering amid reality 

What impressed me most in those areas was the speed of the rebuilding work. Entire shopping malls and neighbourhoods had been razed. But after only twelve months or so, a memorial to Bucha’s 500 dead had already been erected. As we drove through, major construction projects were underway, with multiple cranes towering over rapidly rising apartment blocks and retail parks. 

These are not signs of reality ignored but faced. These are signs of gritted hope. So it struck me that those who keep going amid a siren’s whine are not perhaps ignoring it but taking calculated risks in their perseverance. Just as it is unwise, if not impossible, to live on a permanent adrenaline rush, so one cannot always exist in flight or fight mode indefinitely. It is simply that in wartime, risk thresholds change. Human beings are resilient and adaptable. They endure the most extraordinary setbacks and conditions. 

So, to be with Ukrainian friends in my limited, deficient expression of solidarity, has been inspiring. No one I met had any illusions about the realities of Ukraine’s current plight (especially with a harsh winter looming as Russia systematically destroys power stations). But still they persevere. 

Seeking deeper perspectives of reality 

However, Eliot did not primarily refer to bearing the reality of the mundane. As the novelist Jeanette Winterson explained, Eliot was identifying how little twentieth century society (that of his Waste Land in particular) could bear of spiritual reality. He meant the phenomenon of resistance to a journey towards God or of facing themselves as they stand before God. 

However, the horrors of invasion and the nightly anxieties of air raids have put paid to all that. One friend I was glad to see again is Andriy, previously a fairly well-known Ukrainian journalist and now a church pastor. He regularly goes to the frontline as an unofficial chaplain, visiting troops in their camps and the injured in hospital. He was unequivocal. Before the war they would undoubtedly have been shrugged off. But now, he has not met a single soldier who is uninterested in the things of God and eternity. War has forced them to face their mortality and Andriy has found that most are desperate to talk about little else. These things matter. Even on a beautiful, bright, early autumnal day.

Article
Assisted dying
Comment
Politics
7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

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.