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.

Interview

Assisted dying

Culture

Politics

S&U interviews

13 February 2025

5 min read

Marsha de Cordova: the personal experiences driving her passionate politics

“What disabled people need is assistance to live, not to die.”

Robert Wright

Robert is a journalist at the Financial Times.

A woman wearing a red jacket stands formally beside an office stair case.

When Marsha de Cordova talks about most issues relating to her work as the Member of Parliament for Battersea, in south London, she sticks to the standard position of her Labour party. Meeting at her constituency office by the busy Clapham Junction railway station, she dutifully defends her party’s government, elected last July. She points to ministers’ work to reform planning and improve renters’ rights as evidence they are making progress.

But when conversation turns to the Assisted Dying Bill currently going through parliament, her tone becomes unmistakeably more urgent and her passion more obviously personal.

The strong feelings mark de Cordova out as one of a group of Labour MPs who have been spurred by personal experience and, in many cases, religious conviction to oppose the Assisted Dying Bill introduced by a colleague, Spen Valley MP Kim Leadbeater. While the legislation is a private member’s bill without official government support, it has been widely seen as reflecting the views of Prime Minister Keir Starmer.

De Cordova, who is Black, expresses similarly trenchant views about the government’s rhetoric on immigration. She is also a strong supporter of rapprochement with the European Union.

However, her views on assisted dying – informed partly by being a committed Christian – are particularly forcefully expressed. She answers tersely, “No, I’m not”, when asked if she is happy about the political capital the new government has expended on the Assisted Dying Bill. She adds that she voted against it at second reading, the first parliamentary vote on a bill. She intends to oppose it again at third reading, before it passes to the House of Lords.

“We didn’t need to expend so much capital on it,” de Cordova says. “The aim now has to be to ensure the bill doesn’t pass third reading.”

Many of the Labour MPs who have opposed the legislation have cited religious objections. In the Cabinet, they include health secretary Wes Streeting and foreign secretary David Lammy, both Christians, and justice secretary Shabana Mahmood, a Muslim.

De Cordova also links her opposition to her disability. De Cordova is registered blind because of nystagmus, in which the eyes repeatedly move involuntarily, disrupting vision. There have been fears assisted people could come under greater pressure than others to seek assisted death.

“As a disabled woman, I’m incredibly concerned,” de Cordova says. “What disabled people need is assistance to live, not to die. That should be our government’s priority.”

“My faith is an integral part of who I am. It really is part of my values, my beliefs, my politics.”

The assisted dying fight has garnered unusual levels of publicity for the Battersea MP, who entered parliament seven years ago when barely expecting to do so. De Cordova, now 49, was serving as a Lambeth borough councillor when the 2017 snap general election was called and decided to seek the Labour nomination for Battersea, then held by the Conservatives.

The seat was one of several Conservative seats in pro-Remain areas that fell to Labour’s surprisingly strong showing in the election in the wake of the 2016 Brexit referendum.

“No one really thought I could win here,” de Cordova says. “Obviously, Brexit I would say played a role in that I’m a strong Remainer.”

De Cordova increased her majority in 2019 and last year’s general election. She sees strong continuities between serving as an MP and her previous role in the charity sector. She had been working when elected as the engagement and advocacy director for the Thomas Pocklington Trust, which supports blind and partially sighted people.

“I didn’t grow up wanting to be a politician,” de Cordova says, of her upbringing in Bristol. “I’ve always had the desire to be making a difference. All of my work before becoming a politician centred around that – being that voice for the voiceless.”

She links her work to her faith. She became a Christian in her late 20s and now attends Holy Trinity Clapham. The church is famous as the spiritual home of William Wilberforce and the “Clapham Sect” of early 19th century campaigners against the slave trade and other social evils.

Her faith has led to her appointment as second church estates commissioner – the liaison between parliament and England’s established church, who answers questions in the Commons on behalf of the church.

“My faith is an integral part of who I am,” de Cordova says. “It really is part of my values, my beliefs, my politics.”

It becomes clear speaking to her that her objections to the policies of the government – and the Assisted Dying Bill, which many of her party colleagues support – are clustered around areas involving challenges to fundamental rights.

She objects to the Assisted Dying Bill because she sees it as part of a steady erosion of disabled people’s rights.

“The issue will have a hugely, hugely disproportionate impact on disabled people,” she says. “That, for me, is a no-no.”

Provision for disabled people was “hollowed out” under the last Conservative government, she says.

“That, for me, will always be the issue,” de Cordova says. “I want to campaign and fight for full equality for us.”

She also views immigration issues through the prism of immigrants’ rights.

Asked if she wishes the government took a less hostile tone on the issue, she replies: “From my perspective, when I think about immigration, I tend to think about it in a compassionate way.”

She calls for the establishment of “safe routes” to ensure people fleeing persecution can claim asylum from outside the UK, without making dangerous Channel crossings. The government has shown no signs of introducing such rights.

“Let’s think about immigration in a positive way,” de Cordova says, adding that her grandparents were immigrants to the UK from the Caribbean. “The Tories and the right have always tried to portray it as a negative. It’s not always a negative.”

For de Cordova, the unglamorous role of church estates commissioner forms part of that pattern of advocating for the voiceless.

The job entails dealing with every aspect of MPs’ questions about church life, including the status of historic buildings and other less obviously morally important questions.

However, de Cordova, who was appointed a month before publication of the Makin Report on the church’s handling of abuse by John Smyth, is clear the church has urgent problems to resolve.

The Makin Report has to be a “turning point”, she says.

“I understand steps are being taken to address the challenges,” de Cordova says. “They need to set out over time how they’ll ensure such abuse never happens again.”

The campaigning approach is part of de Cordova’s wider philosophy. She says she has faced many challenges as a result of her disability and tried to overcome them.

“I want to ensure that I can break down the barriers for people coming after me, so that people don’t have to face those same experiences,” she says.

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