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. 

Essay
Comment
Politics
10 min read

England needs a written constitution that defends against populism

A new resolution acknowledges what forges a sense of right and wrong.
A wide angle picture shows a king and queen on thrones before many people in ceremonial clothes.
The Opening of Parliament.
Roger Harris/House of Lords, CC BY 3.0, via Wikimedia Commons.

New Year is often a time for reckoning and resolutions. Nations, no less than individual persons, would benefit from such an annual reckoning with themselves.  

If in life we must always strive to find some Aristotelian ‘golden mean’, between recklessness and timidity so it is in the life of states and nations. Many countries have been brought into ruin by the excess of misdirected appetites and wrongly-ordered desires: demagogues inflaming the people; oligarchs seeking to turn the res publica – the ‘public thing’ – into their own personal fiefdom. Revolutions, corruption and public lassitude are the wages of such sins. Ultimately, it ends in the death of the state itself: the collapse of all legitimate authority into warring gangs, while refugees flee, if they can, to the borders. 

Many countries, conversely, go through their lives in cowed timidity, until they end up in an old age of regret, having never achieved their full potential. These nations do not necessarily collapse, but slowly decline – unable to reform themselves, locked in a vision of their past that was better than their present or any imaginable future.  

 England is at risk of both these dangers. On the one hand, a reckless reactionary populism, which has long laid dormant, but has been unleashed since 2016. It threatens to abandon all prudence and overthrow all restraint, to attack the civil service and the courts, to reject Human Rights, to corrode civic discourse, and to set aside all procedural propriety, until we end up sodden in the gutter of despotism. On the one hand, a persistent constitutional conservatism stands in the way of the necessary, long overdue, reforms which would breathe life and vitality back into an old, tired, country, and would give our institutions the strength to resist such destructive forces.  

Nations, like people, can experience decisive moments of what might be termed repentance. When they wake up in the gutter – their capital city bombed, their army disbanded, their people starving – they can turn from the paths which took them to that place, and find a newness of life, a new hope, embodied in a new constitutional order. This is what Germany, Italy and Japan did after 1945. They can also experience a kind of conversion, away from false principles to truer ones, as much of Central Europe did after the fall of the Berlin Wall.  

I am using theological language here to describe merely civic and political attitudes, which is always a dangerous thing to do. It would be a misreading of my intent if one were to conclude that I conflate a well-ordered polity with the Heavenly City. Nevertheless, a well-constituted polity, in which freedom and justice, peace and the common good, are not only treasured but actually – to some practical extent – achieved, is an inestimable blessing. We should strive to obtain it.  

A well-constituted polity is based upon the principle of ‘public government’. The state is a public entity, belonging to the public, in which public office is a public trust to be used for public ends, and where citizens in public life must be faithful stewards of the public good, for which they are responsible to the public. 

Democracy is our shorthand term for this arrangement, although it is a rather clumsy one. Democracy, properly understood, is not unlimited majority rule, nor the unconstrained rule of the person elected by the majority. It is, rather, a complex political system that combines representative and responsible government with civil liberties and the rule of law.  

Populism is a caricature of democracy. Populists attempt to undermine the barriers that restrain abuses of power. Their attempts to weaken the judiciary and civil service, sideline those who disagree with them, infringe fundamental rights, centralise power, and restrict public dissent, must therefore be seen as attacks on democracy. They put arbitrary power into the hands of particular persons. 

England’s position is not that of Germany in 1945. It might, in some ways, be analogous to that of Central Europe in the 1990s. Much of England today looks like I remember my first visit there then: the same grey faces, the same cheap clothes, the same visible effects of bad housing, bad food, and lack of opportunity. If anything, England is worse off, because at least those countries had hope of better days ahead. No one yet has imagined an English future better than its past.  

England has been let down by a failed ideology – that of neoliberal capitalism, which, as Dr Abby Innes points out, is every bit as rigid and doctrinaire as the official Marxist ideology of the former Communist states. England has been let down, too, by decades of corrupt, incompetent, short-sighted and careless government. The symptoms of misgovernment can be seen in England’s economic record, its social problems, its crumbling infrastructure and over-stretched public services.  Outside the Customs Union and the Single Market, England is isolated from its European neighbours.  The country is not living up to its potential.  

This should spur us to consider the weakness of English democracy. As currently established, the state often fails to serve the common good. The English do not live in a well-constituted polity with ‘public government’ as its foundation, but in a fiefdom-state that has been cut, privatised, deregulated into near oblivion.  

If it were only a matter of specific individuals, or of one party, the problem could easily be fixed. But the country has not only been let down by this government or that government, by this party or that Prime Minister. It is the system of government, the constitutional order as a whole, that has failed us. 

Restoring England’s hope for the future, its prosperity, and its quality of life, must begin, then, with the improvement of English democracy, and that with a refoundation of its constitution. This is hard to hear, because, as Mr Podsnap put it in Charles’ Dickens 1864 novel Our Mutual Friend, ‘We Englishmen are very proud of our constitution, Sir. It was bestowed upon us by Providence. No other country is so favoured as this country.' It is hard to admit that something is broken, when once it was so highly prized – indeed, so intrinsically bound up in England’s sense of national identity. 

The Westminster Model of democracy is not without its virtues. Its origins can be traced far back into English history. Yet it did not develop into maturity in England alone. Bagehot was carried around the world, read under palm and pine, and drilled into the ruling classes from Vancouver to Colombo. The Westminster Model owes much to Magna Carta and Simon de Montfort’s ‘Model Parliament’ of 1295, but it owes just as much to the developments of the Victorian age: (nearly) universal suffrage, political parties, manifestos, and the establishment of a permanent, professional and non-partisan civil service.  

The transformation of Empire to Commonwealth ended British rule, but not the British way of ruling. Westminster Model democracy had to be set down, of course, into a written, supreme-and-fundamental law, through which all the essentials were faithfully reproduced. If you want to discover the Westminster Model of democracy at its peak, read the constitutions of Belize or the Solomon Islands.

The rejection of written constitutions has been a prevailing English conservative principle since Burke. However, it leaves us defenceless against authoritarian reactionary populism. 

The irony is that those who are most comfortable with the imperial legacy are also those who are doing most to destroy public government at home. While fetishizing ‘The British Constitution’ and ‘Our Eight Hundred Years of Unbroken History’, the populist right rejects the principles and the values upon which that achievement rested. Just as they seek to create a pastiche of 1950s Britishness (absent of strong workers’ rights, strong unions, a generous welfare state, and publicly owned utilities and services), so likewise they seek to create a pastiche of the 1950s British Constitution, without the self-restraint, moderation, decorum, public service ethos, and high levels of social trust and cohesion, which made that system of complex unwritten rules work.  

The Blair-Brown reforms of 1997-2010 are a particular target of reactionary ire. The Human Rights Act mitigated, although it did not remove, the absolutism of Parliament. It gave the people who have little voice under a purely majoritarian system – ‘the weird, the wicked, the weak’ – a means by which to challenge the exercise of power. Devolution broke the prevailing English notion of British uniformity: it not only allowed Scotland and Wales to have a (muted) political voice and some (tightly constrained) freedom to craft their own policies, but also forced England into a reckoning with its own national identity. So far, this has played out mostly through the doubling-down on what the former Labour MP and scholar of English identity John Denham calls ‘Anglo-centric British nationalism’. The Tory – and Reform UK – constitutional agenda is obsessed with restoring the unlimited power of Parliament and of reinforcing the Anglo-centric British state. 

As we can see, from every NHS waiting list to every pothole in the road, the Anglo-British state is no longer working very well. It has all the vices of its past, and few of its virtues. A return to the pre-1997 status quo ante is impossible – it would be like trying to retake Hong Kong. Parliamentary absolutism tempered by the ‘good chaps’ theory is no longer a viable option. Either we must accept an untampered absolutism – which is the agenda of the reactionary populist right – or else we must deepen constitutional reform, and arrive at a new constitutional settlement which accepts that the British Imperial state, oriented to the needs of maritime imperial commerce, is over, and that an English nation-state, oriented to the common good of the ordinary people of England, is now needed.  

This entails a new, democratic, constitutional foundation. Small-c conservatives might baulk at this. The rejection of written constitutions has been a prevailing English conservative principle since Burke. However, it leaves us defenceless against authoritarian reactionary populism. Moderate, sensible, responsible conservatives should learn to think differently about written constitutions. Paradoxically, constitutionalism strengthens the state. By bounding and limiting state power, and providing a robust system of responsibility, accountability, and restraint, constitutional government actually enables the state to draw upon a deeper well of public legitimacy.  

What would English identity look like, if it were forged between the Channel and the Tweed, and not between the Nile and the Irrawaddy? What might an English constitution look like, and what values and principles might inform it?  

A constitution for England must recognise that England is a society of many faiths and none. It is, however, an acknowledgment that Christianity has forged and formed not only our institutions, but also our understandings of right and wrong. 

In addressing the last of these questions, the Christian tradition has much to add to the conversation.  

Christian theologians and political philosophers have spilled a lot of ink, in the past two millennia, on questions of good government, on the relationship between church and state, and what it means to be a Christian and a citizen of an earthly state.  

There seems to be an assumption – amongst both supporters and opponents of written constitutions – that a written constitution would have to be based on secular values. This stems, in part, from our ignorance of our own Westminster Model constitutional tradition. The constitutions of the United States and of France might be strictly secular, but the constitution of Antigua and Barbuda claims to be ‘founded upon principles that acknowledge the supremacy of God’, while that of Tuvalu explicitly refers to ‘respect for Christian principles’.  

This is not a bid for theocracy. A constitution for England must recognise that England is a society of many faiths and none. It is, however, an acknowledgment that Christianity has forged and formed not only our institutions, but also our understandings of right and wrong. To give all that up would produce an ethical vacuum in society, which will be filled only with ever more grotesque forms of exploitation.  

The cardinal ethical principle of constitutional democracy is a recognition of human dignity. At the origin and foundation of all institutions, and laws, and norms, we find ourselves having to cling to the fundamental command that Christians call the Golden Rule: ‘Do unto others as you would have others do unto you’. If we abandon that principle of human dignity, there is no solid ground on which to build a decent, well-ordered, democratic polity. Perhaps then we can build a new ‘Jerusalem’ in England’s grey and drizzly land. 

Join with us - Behind the Seen

Seen & Unseen is free for everyone and is made possible through the generosity of our amazing community of supporters.

If you’re enjoying Seen & Unseen, would you consider making a gift towards our work?

Alongside other benefits (book discounts etc.), you’ll receive an extra fortnightly email from me sharing what I’m reading and my reflections on the ideas that are shaping our times.

Graham Tomlin

Editor-in-Chief