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

Belief

Creed

Education

24 January 2025

7 min read

The myth of secular neutrality

Where academia went wrong.

Alex Stewart

Alex Stewart is a lawyer, trustee and photographer.

A phrenology head is shown with its eyes closed.

David Matos on Unsplash.

In the recent horror-thriller Heretic, Hugh Grant plays Mr. Reed, a sharp-witted psychopath who imprisons two missionaries, subjecting them to ceaseless diatribes about the supposed irrationality of all religions. Mr. Reed is also a terribly smug, self-righteous bore, a caricature of the fervent atheist who dismisses faith as mere superstition while assuming atheism is objective and neutral.

This kind of assumption lies behind the criticisms directed by secularists at those who argue from a position of faith, as we saw recently with the debates on the Assisted Dying Bill. Yet, the notion of secular objectivity is itself a fallacy. Secularism, like any worldview, is a perspective, ironically one that is deeply indebted to Christianity, and humanity’s history of abandoning faith and its moral foundation has had disastrous consequences.

Secularism is a bias, often grounded in an ethical vanity, whose supposedly universal principles have very Christian roots. Concepts like personal autonomy stem from a tradition that views life as sacred, based on the belief that humans are uniquely created in God's image. Appeals to compassion reflect Jesus’ teachings and Christian arguments for social justice throughout history. Claims that the Assisted Dying Bill was "progressive" rely on the Judaeo-Christian understanding of time as linear rather than cyclical. Even the separation of the secular and sacred is derived from Jesus’ teaching to “render to Caesar what is Caesar’s and to God what is God’s”. Authors like Tom Holland in Dominion and Glen Scrivener in The Air We Breathe have shown how Western societies, though often disconnected from their Christian roots, still operate within frameworks shaped by centuries of Christianity.

The antidote to human pride and self-deception was to be found in the Almighty. Ironically, it was this humility, rooted in a very theological concern about human cognitive fallibility, that gave birth to the scientific method.

A political secularism began to emerge after the seventeenth century European religious wars but the supposed historical conflict between science and religion, in which the former triumphs over superstition and a hostile Church, is myth. Promoted in the eighteenth century by figures like John Draper and Andrew White, this ‘conflict thesis’ persists even though it has been comprehensively debunked by works such as David Hutchings and James C. Ungureanu’s Of Popes and Unicorns and Nicholas Spencer’s Magisteria. Historians now emphasize the complex, often collaborative relationship between faith and science.

Far from opposing intellectual inquiry, faith was its foundation. Medieval Christian Europe birthed the great universities; this was not simply because the Church had power and wealth but because knowledge of God was viewed as the basis for all understanding. University mottos reflect this view: Oxford’s "Dominus illuminatio mea" (The Lord is my light), Yale’s "Lux et Veritas" (Light and Truth), and Harvard’s original "Veritas Christo et Ecclesiae" (Truth for Christ and the Church). This intertwining of faith and academia fuelled the Enlightenment, when scientists like Boyle, Newton, and Kepler approached the study of creation (what Calvin described as ‘the theatre of God’s glory”) as an affirmation of the divine order of a God who delighted in His creatures “thinking His thoughts after Him”.

Their Christian beliefs not only provided an impetus for rigorous exploration but also instilled in them a humility about human intellect. Unlike modernity's view of the mind as a detached, all-seeing eye, they believed man’s cognitive faculties had been diminished, both morally and intellectually, by Adam’s fall, which made perfect knowledge unattainable. Blaise Pascal captures this struggle with uncertainty in his Pensées.

“We desire truth, and find within ourselves only uncertainty....This desire is left to us, partly to punish us, partly to make us perceive from whence we have fallen.”

For Pascal and his believing contemporaries, the antidote to human pride and self-deception was to be found in the Almighty. Ironically, it was this humility, rooted in a very theological concern about human cognitive fallibility, that gave birth to the scientific method, the process of systematic experimentation based on empirical evidence, and which later became central to Enlightenment thinking.

Orwell was not alone in thinking that some ideas were so foolish that only intellectuals believed them.

Although many of its leading lights were believers, the Enlightenment era hastened a shift away from God and towards man as the centre of understanding and ethics. Philosophers like David Hume marginalized or eliminated God altogether, paving the way for His later dismissal as a phantom of human projection (Freud) or as a tool of exploitation and oppression (Marx), while Rousseau popularised the appealing idea that rather than being inherently flawed, man was naturally good, only his environment made him do bad things.

But it took the nihilist Nietzsche, the son of a Lutheran pastor, to predict the moral vacuum created by the death of God and its profound consequences. Ethical boundaries became unstable, allowing new ideologies to justify anything in pursuit of their utopian ends. Nietzsche’s prophesies about the rise of totalitarianism and competing ideologies that were to characterise the twentieth century were chillingly accurate. Germany universities provided the intellectual justification for Nazi atrocities against the Jews while the Marxist inspired revolutions and policies of the Soviet and Chinese Communist regimes led to appalling suffering and the deaths of between 80 and 100 million people. Devoid of divine accountability, these pseudo, human-centred religions amplified human malevolence and man’s destructive impulses.

By the early 1990s, the Soviet Union had collapsed, leading Francis Fukuyama to opine from his ivory tower that secular liberal democracy was the natural end point in humanity's socio-political evolution and that history had ‘ended’. But his optimism was short lived. The events of 9/11 and the resurgence of a potent Islamism gave the lie that everyone wanted a western style secular liberal democracy, while back in the west a repackaged version of the old Marxist oppressor narrative began to appear on campuses, its deceitful utopian Siren song that man could be the author of his own salvation bewitching the academy. This time it came in the guise of divisive identity-based ideologies overlayed with post-modern power narratives that seemed to defy reality and confirm Chesterton’s view that when man ceased to believe in God he was capable of believing in anything.

As universities promoted ideology over evidence and conformity over intellectual freedom, George Orwell’s critique of intellectual credulity and the dark fanaticism it often fosters, epitomized in 1984 where reality itself is manipulated through dogma, seemed more relevant than ever. Orwell was not alone in thinking that some ideas were so foolish that only intellectuals believed them. Other commentators like Thomas Sowell are equally sceptical, critiquing the tenured academics whose lives are insulated from the suffering of those who have to live under their pet ideologies, and who prefer theories and sophistry to workable solutions. Intellect, he notes, is not the same thing as wisdom. More recently, American writer David Brooks, writing in The Atlantic, questions the point of having elite educational systems that overemphasize cognitive ability at the expense of other qualities, suggesting they tend to produce a narrow-minded ruling class who are blind to their own biases and false beliefs.

It was intellectual over-confidence that led many institutions to abandon their faith-based origins. Harvard shortened its motto from "Veritas Christo et Ecclesiae" to plain "Veritas” and introduced a tellingly symbolic change to its shield. The original shield depicted three books: two open, symbolizing the Old and New Testaments, and one closed, representing a knowledge that required divine revelation. The modern shield shows all three books open, reflecting a human centred worldview that was done with God.

However, secular confidence seems to be waning. Since the peak of New Atheism in the mid-2000s, there has been a growing dissatisfaction with worldviews limited to reason and materialism. Artists like Nick Cave have critiqued secularism’s inability to address concepts like forgiveness and mercy, while figures like Ayaan Hirsi Ali and Russell Brand have publicly embraced Christianity. The longing for the transcendent and a world that is ‘re-enchanted’ seems to be widespread.

Despite the Church’s struggles, the teaching and person of Christ, the One who claimed not to point towards the truth but to be the Truth, the original Veritas the puritan founders of Harvard had in mind, remains as compelling as ever. The story of fall, forgiveness, cosmic belonging and His transforming love is the narrative that most closely maps to our deepest human longings and lived experience, whilst simultaneously offering us the hope of redemption and - with divine help – becoming better versions of ourselves, the kind of people that secularism thinks we already are.

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