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

Justice

20 February 2025

7 min read

Just where does the arc of history bend towards today?

What happens when the optimism bubble bursts.

Roger Standing

Roger is a Baptist minister, author and Senior Research Fellow at Spurgeon’s College in London.

The feet and legs of someone walking on a white rug, beside the words Justice and Government woven in to it,

Obama's Oval Office rug.

The White House, via Wikimedia Commons.

"Yes we can!

Yes we can!

Yes we can!"

There was something magical about hearing Barak Obama speak to a crowd. The rhythm of his sentences, the rhyme of his words and the melodic cadence of his baritone delivery had the ability to hold you spellbound. It felt so positive, so uplifting, so inspiring.

The call and response with the audience only underlined the positivity of the impression: ‘Yes we can!’

It was listening to Obama that I first heard the quote:

‘The arc of history is long, but it bends towards justice.’

I loved it. Obama used it a lot, and so did I.

It seemed to epitomise the hopefulness his presidency embodied. Implicitly, it advocated the qualities of patience and persistence that are so important in working for a better world. It doesn’t happen overnight. It also acknowledged his rootedness in what had gone before, ‘As Dr King used to remind us …’. Obama was borrowing the line from one of his own heroes.

In fact, the quote was with him all the time in the Oval Office of the White House, to the right of his desk. Along with four other quotes it was woven into the perimeter of a 23 by 30-foot oval rug that almost filled the room.

The one-liner still delivers a punch, just as it did for Martin Luther King. However, I am increasingly convinced that it doesn’t stand scrutiny. As much as I want it to be true, and long for it to be true, I do not believe that it is.

The sentiment was of its time. Not the 1950s and 60s of Dr King, but the 1850s of the Unitarian minister Theodore Parker from Massachusetts. The germ of an idea originated with him in a sermon entitled, ‘Of Justice and the Conscience’. At this point it was a complicated paragraph rather than a pithy one-liner.

‘You see a continual and progressive triumph of the right. I do not pretend to understand the moral universe, the arc is a long one, my eye reaches but little ways. I cannot calculate the curve and complete the figure by the experience of sight; I can divine it by conscience. But from what I see I am sure it bends towards justice.’

Parker was also responsible for ‘government of the people, by the people, for the people’ that Abraham Lincoln would go on to cut and paste into his famous Gettysburg Address during the Civil War. It also appeared on Obama’s rug.

The intellectual circles of the 1850s were alive with many new ideas like progress, equality and the abolition of slavery, and ‘transmutation’ (or evolution as it would become known). In science, industry and social life things were moving forward and getting ever better.

As the century moved on this conviction continued to grow and become more widespread. By the early years of the twentieth century Parker’s thought itself had been distilled down into the single line we’re familiar with and included in popularly published collections of aphorisms.

Prosperity and progress informed the narrative of Western culture and ideas of evolution were imported into other disciplines. In anthropology, for example, this gave rise to ‘social evolutionism’ and the categorisation of societies into a developmental sequence ranging from ‘primitive’ to ‘civilised’.

Of course, it doesn’t take much imagination to recognise that there was a darker side to such notions. Here was also an underpinning for a colonial worldview and an intellectual justification for racial hierarchy. Western culture was more ‘evolved’.

These views were epitomised in psychology where, for example, in Freud’s Totem and Taboo (1913) he speaks of indigenous people as ‘the most backward and miserable of savages’, comparing the way they live with features of a neurosis and mental disorder.

The carnage of the First World War effectively popped the bubble of an overly optimistic ‘progressivism’. I do wonder whether we are now at another ‘bubble popping’ moment in the West.

Is your ‘bubble of optimism’ in danger of popping, or has it even popped already, like mine?

In the decades since the Second World War we have succumbed to our own narrative of progress. We have witnessed amazing technological advances and stunning scientific discoveries. The forward movement is obvious, and the promise of an even better future is clear.

Then, supported and monetised by the market economy, our lives are tempted, enhanced and festooned by the latest products and services that our money can buy. From smart doorbells to wearable tech and TikTok to ChatGPT our world is constantly changing and upgrading and the movement forward is undeniable.

The narrative runs in our wider life too. We celebrate the triumph of the suffragettes, the defeat of fascism and the collapse of old-school communism. Francis Fukuyama may have been premature declaring the end of the Cold War as the ‘end of history’ in 1989, but it did seem like Western-style liberal democracy was what the world was striving for.

Then there are the advances in our shared life together in Britain. If Acts of Parliament in some measure illustrate the pulse of the nation, the direction is clear. Take, for example:

the Sexual Offences Act 1967
the Sex Discrimination Act 1975
the Race Relations Act 1976
the Childrens’ Acts of 1986 and 2004
the Disability Discrimination Act 1995
the Human Rights Act 1998
the statutory instruments protecting against discrimination in employment on grounds of religion or belief (2003), sexual orientation (2003) and age (2006)
the Gender Recognition Act 2004
the Equality Act 2010
the Marriage (Same Sex Couples) Act 2013

This list isn’t exhaustive and there are campaigners who are very keen to add to it. But we live inside this narrative, and we know the plot. It is familiar to us. And it would be so easy to be seduced into a new myth of inevitable progress, ‘The arc of history is long, but it bends towards justice’.

‘Social evolutionism’ was so deeply embedded in late Victorian culture that its ‘self-evident’ truth went largely unchallenged. The vast majority believed their own hyperbole and complacently embraced the fruits of burgeoning industry and an expanding empire. They lacked the self-critical capacity to comprehend the flaws in their worldview and to understand what their world was capable of in the infernal, apocalyptic catastrophe that was unleashed in 1914.

Maybe, embracing a more contemporary myth of progress has a similar effect on us. We presume that our way of life will inevitably continue moving forward unchallenged. That we have a right to experience a tomorrow that will always be better than yesterday. And that those who do not subscribe to our notion of ‘progress’ are clearly inferior, ill-informed or backward in some way. But such a mindset also lacks a culturally self-aware and critical edge and is oblivious to how easily things could fall apart.

At this moment in time the world seems far less secure than at any point in my lifetime. Our community hosts refugees from Ukraine and Hong Kong, a friend has only recently returned from working with a voluntary agency in Israel and I am about to meet up with another friend who has just flown in from the United States.

Populist, anti-democratic and disruptive forces are more blatantly at work around the world than for many a long year. Developments in AI, cyber-terrorism and digital warfare create a disembodied sense of ‘existential threat’. And then there is the climate crisis. Fires in California, floods in Europe and the unprecedented sequence of six tropical cyclones in the Philippines in late 2024 seem to have had little impact in accelerating the response to global warming.

Is your ‘bubble of optimism’ in danger of popping, or has it even popped already, like mine?

Of late I have found helpful insight in observations made by Jesus. Rather than fixating about what might happen in the future, he encouraged those who had attached themselves to him to live in the moment,

'Therefore do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.'

For those who were concerned about what might be happening and felt the world was falling in around them, he offered reassurance. He counselled that such events did not signal the end of the world. Rather, this was simply the kind of thing that happened.

'You will hear of wars and rumours of wars, but see to it that you are not alarmed. Such things must happen … these are the beginning of birth pains.'

Rather, the early Christian ethic was rooted in God’s loving, supporting and strengthening presence during unstable times.

Writing to the Christian community that had formed itself in Rome, the apostle Paul was convinced that whatever befell them – trouble, hardship, persecution, famine, nakedness, danger, or weaponised violence – that nothing would be able to ‘separate us from the love of God that is in Christ Jesus our Lord.’

And right at the base of this ethic that Jesus advocated was an unswerving commitment to ‘love your neighbour as yourself’

Which takes us back to Obama’s rug and the West Wing office.

On the left-hand side of his desk was a quote from President Theodore Roosevelt:

'The welfare of each of us is dependent fundamentally upon the welfare of all of us.'

And that really is it. History may not bend towards justice, and hard-won progress we’ve achieved can likewise be lost, but our future will always hang on the ‘welfare of all of us.’

Well said Mr. President!

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