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
America
Comment
Politics
Race
13 min read

A raging election and the haunting of American memory

Civil War lessons on what ‘we the People’ choose to remember or forget.

Jared holds a Theological Ethics PhD from the University of Aberdeen. His research focuses conspiracy theory, politics, and evangelicalism.

A US flag flutters under a dark brooding cloudy sky.
Roger Hoover on Unsplash.

Foreboding. That’s how my friend described the time between now and the election in America. It’s everywhere, and nowhere. It’s felt, it’s lived, it’s immediate. And it’s true, there is little reason to carry ourselves as though this election will be anything other than consequential—immediately so—for at-risk communities across the United States, from hurricane survivors to Haitian-Americans.   

We would do well to pay attention to this. And for me, as an American citizen, I plan on casting my vote against Trump, for what I wager to be a better path towards provisional freedom. But there’s a part of me that remains attentive to the stakes and the perils that lie beneath the immediate. 

As you survey the landscape of the American experiment, you will find it marred not just by scars of racial hatred and violence, but the shadows of things forgotten and repressed. Looking over it long enough will reveal the chasm between America’s living memory and its history. It’s here, surveying that great landscape, the gap emerges between what “We the People” choose to remember and what we’ve deigned to forget. And this memory—as much as the polls and the data predict—will influence what is to transpire these next few months. 

As we bear witness to the events unfolding before us, we would do well to remember how “We the People” have never truly resolved our Civil War. Our memory of the war is both hallowed and haunted.  

If onlookers and participants alike want to understand—really and truly—the crucible of this American election you have to descend to the depths of American memory, into its distortions and attempted preservations. You have to understand not just the Civil War itself, but its ongoing aftermath, from a period called Reconstruction to the century later Civil Rights struggle, and on to today. Recently I heard historian Jemar Tisby share an anecdote of something uttered by a Gettysburg battlefield tour guide, “The north won the war,” he said, “but the south won the memory.” 

Who has time for a history lesson? I would submit the stakes are too great, and the need too earnest, to ignore. 

Memory is a fickle thing. But it is also a moral thing. Memory gathers the resources from which individuals become a “we.” That is the point where everything begins to change, observes John Steinbeck. That move from “I” to “We,” he called it. Memory can create a people. From it, a “we” can draw strength, clarity, and courage for the present, it can also reap the whirlwind.  

Theologian Stanley Hauerwas captured the stakes when he observed, “memory is a moral exercise.” And in a moment where the American social fabric seems to be rending at the seams (not at all an unprecedented event), I think part of staying the course involves turning again to the moral power of memory. To remember what we’ve forgotten, to surface what has been buried.  

But in the middle of an election cycle endlessly bombarding Americans with hate, disinformation, and propaganda, the turn to memory might seem little more than idealism. Who has time for a history lesson? I would submit the stakes are too great, and the need too earnest, to ignore. The problem is: the American memory is distorted and divided. 

Ruby Bridges visits Barack Obama at the White House to view 'The Problem We Have To Live With' on its walls, 2011.

Barack Obama and a middle aged black woman look at a picture of her when she was a child walking between guards protecting her.

In 1960, a six-year-old girl by the name of Ruby Bridges became the first African American to attend William Franz Elementary School in New Orleans. She walked into the school that day surrounded by armed guards, assigned to protect her from public fury in the wake of a federal court order enforcing integration across New Orleans Public Schools. 

Ruby became an icon of the Civil Rights struggle of the Sixties. She was canonized by artist Norman Rockwell in a piece aptly titled, “The Problem We All Live With.” Between that painting and hundreds of photographs that captured her bold yet innocent stride up those school steps with books in hand, Ruby Bridges was impressed into American memory.  

Consigned to these mists of memory, Ruby Bridges appears as perpetually six years old to many white Americans. But one fact pierces the mists of memory: Ruby Bridges has an Instagram. Though her memory in white America reduces her to an image frozen in time, she is a woman alive today in her sixties with an incredible ongoing career in advocacy and activism. The cries of “woke!” that emerge in every conversation about justice and equity in America cannot silence the reality of time: the Civil Rights struggle is not so distant as white Americans often insist it was. What we remember is tragically the result of what we’ve tried to forget. 

But whenever the church settles to serve as a chaplain of empire, it soon confuses the privilege and luxury it secures with its own freedom.  

We tend to think of history as objective, as a set of facts. And this obscures how our own memory of history can be distorted and warped. Consider this past month that former US President Jimmy Carter turned 100 while in hospice care. His birthday made mainstream news. An impressive lifespan to go with an incredible legacy as a husband, father, and public servant. But the American memory is strange. Strange because Carter, the oldest living US President, is still with us. Making it all the more startling to remember that the Rev. Dr. Martin Luther King was born 5 years after President Carter. That, if not for an assassin's bullet at a Memphis hotel balcony in 1968, Dr. King could have been celebrating his 96th birthday this coming January. Memory can be distorted, warped, and pressed into service of propaganda. 

Too often, the white church in America has made itself fit for service as a chaplain of empire. Willingly producing, baptizing, or consuming memories which obscure the truth that brings about reconciliation. In so many words, we have in America today a more reactionary and partisan element of the church. One that cannot take the moral responsibility of memory seriously because it finds itself too invested in its role of reifying and deifying America. And whenever the church settles to serve as a chaplain of empire, it soon confuses the privilege and luxury it secures with its own freedom. Because many white churches confuse this power with freedom, the memory of America is captive to its own ends. It is not free. It does not know the freedom which liberates the church to the moral task of memory. 

I think here of Dietrich Bonhoeffer’s claim that the church can never take immediate or “direct” political action as church because, as the community of God’s people it “does not know the necessary course of history.” The church does not possess special access to the ideas of the future, nor does it consign the world to fate. What the church is, it is as witness. It testifies in the bread, the wine, the water of the liberating presence of God. But when the church acts apart from this vocation it risks becoming what Ernst Kasemann called the “anti-church” which replaces the cross with power. 

I find this a broadly accurate depiction of what the white American church presently offers to the American public. It is not the beloved community and conscience of the nation to which Martin Luther King Jr. spoke, rather it is a chaplain of empire. And in this role, the church finds itself both a producer and consumer of a distorted memory, filled with a mixture of sentiment, propaganda, and raw fact. A story of America in service of a particular vision of America which never existed. 

Is this not too political for the church? Mustn’t we keep religion and politics separate? All theology is political. That is, all human talk about God involves consequences—for good or ill—concerning fellow human beings. James Cone puts it more directly: “Any talk about God that fails to make God's liberation of the oppressed its starting point is not Christian.” The difference then is not whether the church is political, but rather whether its talk about God is indeed talk which remembers in a living way the God of Jesus Christ, and whether or not it opens itself up to the critical examination of its own god talk. And this is where we find a good deal of the white American church today. 

Even the mention of the “white church” in America should stir up the paradoxes and contradictions which persist in the field of American memory. But perhaps we too easily confuse “history” with “memory.” Memory is living, fluid, and potent. I like how Robert Jenson puts it, “so long as a people is alive, there will be an exchange between how it remembers its history at any given time and its needs, concerns, and goings-on in the present. There is thus usually a difference between a people’s own living memory…and the accounts constructed by historians…” Jenson was talking about the Old Testament. Here, we reflect a bit on the American experiment.  

I remember in 2020, as a pastor, I sat in a prayer night at the church where I served on staff. But there was not much praying. Instead, we were shown a video selected by our senior pastor. The video was a tour of Washington D.C. highlighting all the Christian imagery and inscriptions scattered across the American capital. I’ll never forget the words that came from my pastor: “The next time,” he said, “anyone tells you America isn’t a Christian nation, you tell them about what you learned here tonight.” And that was it. The video never mentioned many of the buildings were built by the hands of people enslaved in an institution justified by a most bankrupt faith. 

I’ve come to understand that every church in America, even with the Christian story on its lips, tells a story about America, too. And the memory of that story carries with it theological consequences. After all, there can be no quicker way to discredit human words about the God of Jesus Christ than to attach those words to a false memory of America masquerading as dogma.  

The statute of General Longstreet, Gettysburg battlefield.

An equestrian statue of an American Civil War general wheeling his horse.

Stranger still was realizing the church I served was constructed on a piece of land in Virginia’s Spotsylvania County lined with historical markers. One identifies the land as the camp site of Confederate General James Longstreet during the Fredericksburg Campaign of the Civil War. Tellingly, Longstreet’s own life and legacy gives witness to the enigma of memory and also the possibility of change that arises from the wedding of truth and reconciliation. 

Longstreet was long known as General Robert E. Lee’s right-hand man. He devoted himself to the Confederate cause in defense of slavery. And stood by Lee till the end of the war, joining him at Appomattox, Virginia, where he was reunited with his foe and friend, Union General Ulysses S. Grant. Instead of imposing harsh penalties on the Confederates, Grant proved reconciliatory in ways that Longstreet never forgot, according to his biographer, Elizabeth Varnon.  

In fact, Longstreet became an ardent supporter of Reconstruction policies and Civil Rights, including the vote, for formerly enslaved people. His transformation made him an enigmatic figure that attracted the bitter hatred of fellow former Confederates seeking a scapegoat for the South’s defeat. They found their sacrifice in Longstreet. 

After the war, Longstreet settled in New Orleans for business. In 1872, there was a disputed election between pro-Reconstruction Republican governor and the Democrats. Longstreet answered the call from the Republican governor to lead a “mixed” regiment of African Americans and white Americans against a renegade paramilitary force comprised mainly of disgruntled Confederate veterans. These paramilitary groups opposed the African American vote and Reconstruction policies in general to the point of violence. 

In a historical episode that echoes January 6, 2021, Longstreet, a former Confederate General, led this Reconstruction regiment against white paramilitary insurrectionists seeking to subvert the election and install their own governor. The clash became known as the Battle of Canal Street. But its original name was given by the nearly successful Confederate paramilitary: “The Battle of Liberty Place.” This was the name affixed to a monument erected in 1891, which stood in New Orleans until it was removed under cover of darkness for fear of political violence in 2017. 

The stark transformation of Longstreet’s life and career does not make the man a saint. He clung to racist ideologies until his death. To emphasize his support of Reconstruction is not to canonize him as much as it is to highlight the enigma of American memory. That, in the wake of the Civil War, the conflict over Reconstruction proved so destructive that eventually whites from the North and the South opted to reconcile at the expense of Civil Rights. In the contested Presidential Election of 1877, Republicans accepted the Presidency in exchanged for the Democrat’s demand for an end to Reconstruction and a withdrawal of Federal troops. The dealings of 1877 made Jim Crow America possible, and forestalled gains of the Civil Rights movement for nearly another century. And the question remains open: will America ever deliver on its promises? This is the appeal made by MLK and others. 

And our failure to remember as Americans is, surely, part of the task of the church in America. For a witness to the Christian story surely involves a freedom to speak truths of our common life and history which make for reconciliation. For me, as the election nears, I’m thinking of the enigma of Longstreet and the distortion of American memory. 

For in the very church that claimed America was a “Christian nation” merely by virtue of slogans fixed atop our public buildings, there was along with it a willed ignorance to matters of race in our own community. I experienced enforced silence on just how far a pastor might talk about race before being “too political” or “divisive.” I found there is a tragic irony of failed memory in gathering to worship on land once occupied by Longstreet’s camp, the man who supported Civil Rights and resisted an insurrection. After I left, I learned the church’s parking lot was made available for busses attending the event that metastasized into the January 6 insurrection. And just this past month, thousands of evangelicals descended once again into Washington DC, praying and declaring Trump’s victory against Harris. Here too, the whitewashing of January 6 has its own consequences. 

Amid the raging fury of an American election cycle, memory can help provide perspective, so long as we are willing to incriminate ourselves with the sins of forgetfulness and short-sightedness. There are events forever etched into our collective memory, to be sure. We have slogans for them. Like “Remember Pearl Harbor” and “Never Forget” for 9/11. But even here, amidst cries to remember, our memory persists in a state of perpeutal division and distortion. The slogans we create to remember the tragic dead too easily become transformed into a license for our unflinching commitment to the myth of redemptive violence. 
Again and again we see, memory carries moral power. And without truth in our memory, there can be no reconciliation. But I remain hopeful precisely because I do not worship fate. The confession which binds Christian community speaks of the God who reconciles. This reconciliation is received as a grace by the truth of Jesus Christ.  

Whether or not “We The People” renew our capacity to speak the necessary truths, to live in that light, and so prove reconciliation to be a lived reality not mere sentiment, depends in no small part on the willingness of Christian community in America to take up the fuller and deeper ministry of reconciliation bound up in our confession. Such a ministry cannot be one of external compulsion, of endorsing authoritarian politics and programs in the name of another crusade. Rather, it is one that begins and ends with the question of whether the church will be the church. Whether or not America continues as America does not rest on the church. And freed from this strange, alien imposition, the church may find itself all the more fit to help America remember and so tell the truth and reconcile together. 

So long as we Americans allows ourselves the freedom to recognize the inherent relationship between truth and reconciliation, perhaps we can carve out a higher vantage point from which the stakes and perils of this election become a bit clearer and stir in us a bit more courage to persevere in what Lincoln spelled out over a century ago, a new birth of freedom and government of, by, and for the people…all the people. And may the church stand to testify that this temporal freedom is only a fleeting harbringer of a freedom which comes to all humanity through the scandal of a cross and empty grave.