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

Grenfell disaster

Trauma

6 February 2025

6 min read

Grenfell: how long should we remember?

There are good and bad ways of remembering.

Graham Tomlin

Graham is the Director of the Centre for Cultural Witness and a former Bishop of Kensington.

A white building wrap around a tower is topped by a green heart and the slogan: Grenfell Always In Our Heaets.

Grenfell Tower, Summer 2024.

Rc1959, CC0, via Wikimedia Commons.

For nearly eight years now, Grenfell Tower has remained standing as a reminder of one of the most painful days in recent British history. The news that the government intends to dismantle the remains of the Tower has split local opinion. Some of the bereaved and survivors suggest that the government has scarcely consulted them. For many, the building is a tomb, still containing the memory, if not the actual remains of their loved ones whose bodies could not be recovered. They understandably fear them being forgotten when the building no longer stands as a reminder. Last year I sat in on a gathering where bereaved families and survivors of the fire told their stories in the hearing of representatives of the companies who were responsible for the cladding which caused the fire to spread. The memories and emotions are still raw and unhealed.

On the other hand, many local residents would like it taken away, as its constant, looming presence is a painful reminder of that dark night. They also see the logic in bringing down a fatally damaged and increasingly dangerous structure that costs the taxpayer millions each year to keep from collapsing under its own weight.

The key issue at the heart of this debate is how we remember - especially, how we remember pain. In the rhetoric around Grenfell, as with many other tragedies, we often hear calls to ‘always remember’ and that we must ‘never forget’ the wrongs done which caused the deaths of those 72 people. The Grenfell Memorial Commission, which was charged with thinking about what memorial should stand on the site of the building in future, claimed as its aim to “make sure the Grenfell tragedy can never be forgotten.”

Such calls to ‘never forget’ are powerful. They seem a proper tribute to those who died, they ensure that those culpable are not let off too easily, and that justice is properly done. To blithely forget such horrendous evils seems an affront to justice, and a morally culpable act.

Yet must we always remember the hurts and pains of the past? Can we imagine a future where such memories fade into the distance and no longer cast their painful shadow over our lives?

Whether and when Grenfell Tower comes down, is yet to be determined. Yet only when we keep in mind the destination of the journey of healing can we make good decisions...

Theologian Miroslav Volf asks all these questions in his book The End of Memory. He describes good and bad ways of remembering. We can remember to cherish the dead, to learn lessons for the future, to ensure justice is done. Yet we can also remember to nurse grievances, to cling onto grudges, to imagine horrible pain inflicted on those who wronged us. Memories of wrongs done to us can imprison and define us purely as victims, never in control, always subject to the actions for others, with no agency of our own.

Volf’s Christian faith tells him that the human race is beckoned towards a new world, in the full presence of God, of what he calls ‘final reconciliation’. It is a place where we will be captivated by a vision of the beauty and goodness of God, a vision that we only dimly glimpse in this world. He asks the question: in such a world, will we remember all the wrongs done to us? Can we imagine still clinging onto the memory of the sins and crimes that others inflicted on us? Even if that were in principle possible, would we remember all the harm done to us? And the harm we did to others? If not, which sins would we remember? Which ones would we forget? Would not such memories blight the joy that such a world would surely offer?

Reflecting on his own youthful and painful memories of interrogation in communist Yugoslavia, and other tragedies such as the 9/11attacks, Volf imagines getting to the point where we don't forget the terrible things that others have done to us, but when we actively don't remember them. They still occupy a place in our minds but are instead relegated to a corner of our consciousness, under our control, no longer rearing their ugly and painful heads when triggered by other events. Such an ability not to remember, he suggests, is a good thing:

"Non-remembrance of wrongs suffered is the gift God will give to those who have been wronged."

At the same time, Volf is careful not to imagine getting to this point too easily. Wrongdoers cannot for a moment insist that those they have wronged forget their misdeeds. Such non-remembrance can only happen when truth has been told, sins punished, and justice done. Yet when all that has taken place, that ‘final reconciliation’, Volf imagines, might even embrace the unimaginable - an ultimate reconciliation between the wronged and the wrongdoers.

Is it possible to imagine children whose parents were killed because of the negligence and culpable cheating of contractors who knowingly put unsafe cladding on Grenfell Tower, ever being reconciled to and even embracing the perpetrators? Volf suggests we can, while recognising that this can only happen when the crime has been identified, fully recognised, repented of profoundly, forgiveness offered and accepted and the appropriate penalty paid.

While such a process remains incomplete, the obligation to remember remains, and reconciliation cannot yet take place. But true healing from such hurts is not to be forever dominated by them, defined by them, or to live in constant enmity and resentment because of them. It is, instead, to gain the strength and ability not to remember them, not to be defined by them, and even - possibly, perhaps - to find reconciliation with their perpetrators.

The Grenfell Public Inquiry that reported last year was an important step for the bereaved and survivors. It was not the end of the journey. Far from it. The process of enacting justice through prosecution of the guilty lies ahead. But as an exercise in truth-telling, in giving perpetrators the opportunity to own up and confess their guilt, in a truthful recognition of what went wrong, it was a vital step towards the possibility of reaching that stage when the memory of Grenfell no longer defines its victims. It opens up the possibility at some point in the future, where they might be in control of their memories rather than their memories controlling them.

The Danish Christian philosopher Søren Kierkegaard once wrote that we humans need to learn both “the art of forgetting” and “the art of remembering”. To know when and how to do one and when to do the other is the gift of God and an art of true wisdom.

Whether and when Grenfell Tower comes down, is yet to be determined. Yet only when we keep in mind the destination of the journey of healing can we make good decisions about such fraught and emotionally charged issues. The Tower cannot remain as it is - everyone acknowledges that . Yet it's hard for many to think about its disappearance without knowing what will replace it. Which is why plans to demolish the Tower must go hand in hand with the plans for the lasting Memorial that will stand on the site. Yet that can only happen if it serves the goal of being able truthfully to remember no longer the pain and injustice of the past.

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