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

Gaza

Israel

Politics

4 October 2024

7 min read

Israel-Gaza war anniversary: why peacemakers need a touch of doubt

Which narrative do you believe?

Graham Tomlin

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

Split-screen on TC shows many different news channels in English, Arabic and Hebrew.

Split-screen reporting.

Al Jazeera.

As the focus of the crisis in the middle east shifts from Gaza to Lebanon, and as the anniversary of the October 7th attacks comes round, a look at the narratives that surround this conflict helps chart a way forward.

At the heart of the Middle Eastern crisis involving Israel, Gaza and now Lebanon, are two very different stories.

One of them goes like this.

Israel is the only properly functioning democracy in the Middle East. It is a sanctuary for the Jewish people who over centuries, and around the world, have experienced extraordinary levels of persecution and discrimination. As a small country it has bravely established itself over the past 76 years as a haven of liberal, democratic freedom and prosperity despite the hostility of its neighbours, such as the Iran-backed Hezbollah in Lebanon. The Hamas attacks on October 7th 2023 were an unprovoked murderous assault on innocent citizens, the butchery and savagery of which was unprecedented in recent times. Hamas and Hezbollah both represent an Islamist ideology which has been a recurring thorn in the flesh of all democratic states, and which has taken root in Gaza and Lebanon. Israel's response of attempting to drive out such a deadly enemy from neighbouring states is entirely justified and reasonable. Any country faced by neighbours dedicated to its destruction would do much the same. Yes, there are civilian casualties in the conflict, but there always are in war. To oppose Israel’s campaigns in Gaza and Lebanon is in fact to lend covert support for terrorism, and a form of antisemitism, because it challenges the right of Israel, and the Jewish people, to self-determination and self-defence.

Yet there is another other story, which runs thus: At the time of its founding in 1948, the pioneers of the state of Israel committed an original sin which has plagued it ever since - its expulsion of much of the indigenous Palestinian population from the land in the Arab-Israeli conflict which followed the founding of the state. Ever since then, Israel has sought to subjugate the remaining Arab population, treating Palestinians within its territory as second-class citizens. Since 1967, it has illegally occupied the West Bank and Gaza, denied Palestinians basic rights of civic equality while enabling and encouraging Jewish settlers to gradually steal land which is recognised by the United Nations as Palestinian. Within Israel and the Occupied Territories, Palestinians find it harder to get building permits, to find jobs, to be properly represented in parliament or to have opportunity for education. Therefore, it is not surprising that that the simmering resentment such treatment provokes leads to occasional resistance such as in the intifadas of the 1990s and 2000s, the election of Hamas in Gaza, and even the attacks of October 7th. Israel regularly accuses anyone who criticises its policies of antisemitism, using it as a shield to hide its mistreatment of the Palestinian minority. It has used the occasion of the October 7th attacks to launch a massive assault on Gaza and now southern Lebanon, regardless of the civilian casualties. The result is, at least in Gaza, a humanitarian disaster which will takes, years, even decades to resolve.

Which of these narratives do you believe? Depending on a whole set of other commitments you probably resonate with one or the other. If you are more left leaning you probably favour the Palestinian account. If your instincts are more right-wing you will tend to favour the Israeli one. And I’m sure you can pick holes in the opposite narrative if you want to.

Christians fall on both sides of this debate. Christian Zionists tend to see the emergence of the State of Israel as a fulfilment of Biblical prophecy that God would one day bring the Jewish people back to the land from which they were exiled in the distant past. Supporters of the Palestinian cause point to the Bible’s injunctions towards justice, its regard for the poor and oppressed, and to Israel’s Old Testament calling to look after the alien within their nation. Surely Israel has a duty to treat the Palestinians within their borders as equal citizens?

To love your enemy does not mean to pretend that your enemy is a friend - at least not yet.

So, does Christianity bring anything to this conflict? Or is it just as divided on this issue as anything else?

One the most distinctive notes in the teaching of Jesus is his remarkable and unprecedented, some would say ridiculous call to love your enemies and pray for those who persecute you. It was - and is - standard human behaviour to love your family and friends. It's more of a stretch to love your neighbours who happen to live next door. It's a whole different ball game to love your enemies. The phrase trips off the tongue as one we know well, yet how could it ever be possible for Israelis to love or pray for Hamas fighters, or the inhabitants of southern Lebanon to love the nation across the border to the south that is shelling them each day?

I cannot even begin to imagine that. Yet closer to home, how does this idea of love for enemies effect our approach to these two stories, held so passionately on both sides of the debate? I first visited Israel/Palestine in 1989, in the middle of the first Palestinian ‘intifada’ or uprising against Israeli occupation. I stayed in east Jerusalem with Christian Palestinians and heard and saw first hand their feeling of resentment at being treated as inferiors in a land which had, they claimed, until the ‘Nakhba’, or ‘Catastrophe’ of 1948, been theirs for centuries. I came back full of righteous zeal for the Palestinian cause and would talk to whoever would listen about the injustice of Israeli treatment of the Palestinian people. I wanted people to imagine what it would feel like to know your family’s ancestral land was taken at gunpoint in 1948, to have to go through humiliating checkpoints to get to work, to have a neighbouring Jewish settlement harass your children and family, trying to get you to leave your home, so they can take the land, with little or no support from your own government or the police. And, in many ways, I still do.

Yet over the years, and on numerous visits back to the Holy Land, I’ve gradually begun to try to see the story from the other perspective as well. Listening to the voices of Jewish people both in Israel and here in the UK, I've tried to imagine what it would feel like to be part of a people that has been hunted down in pogroms stretching back into a shameful past, including the expulsion of Jews from Arab countries in the twentieth century and the attempt of a modern European state to exterminate that people entirely. I've tried to understand their hope in the state of Israel as a place of security and their desperate need for it to survive and thrive as a place where Jews can feel safe, even as real antisemitism does from time to time raise its ugly head elsewhere in the world. Alongside Palestinian memoirs such as those from Sari Nusseibeh and Elias Chacour, I read Jewish writers such as Alan Dershowitz and people like Ari Shavit who captures the dilemmas of liberal Israelis caught between lamenting the expulsion of the Arabs in 1948, yet enjoying the fruits of that period in the present.

I still yearn for Palestinian friends to find peace and equality, but realise that like so many enduring issues in world politics – it’s complicated.

To love your enemy does not mean to pretend that your enemy is a friend - at least not yet. Many people reading this will have passionate commitments to one story or the other. Yet surely to love our enemies does mean to try to begin to see the story from another perspective, to try at least to put yourself in the shoes of the other, to entertain for a moment a little bit of doubt about the certainty of your own moral case.

Loving your enemy might well be a ridiculous, impractical idea. Yet the alternative is hardly turning out well.

It is what some within the land of Israel have tried to do. Salim Munayer and Lisa Loden are, respectively, Palestinian and Jewish Christians. Their book Through My Enemy’s Eyes tries to do just that – showing how Palestinian and Jewish Christians read the same Bible through different lens, and beginning to imagine how some form of reconciliation might be possible. Organisations like Musalaha and Telos are trying to buck the trend, helping each side meet the other and begin to imagine what reconciliation might look like.

Loving your enemy might well be a ridiculous, impractical idea. Yet the alternative is hardly turning out well. If Israeli radicals were to succeed in expelling all Palestinians from the West Bank or Gaza, or Hamas / Hezbollah were to succeed in expelling the Jews from Israel - Neither is a solution that speaks of justice.

It is hard to imagine any progress towards peace without something of this attempt to try to understand a different perspective. You cannot build peace without being a peacemaker – a figure often misunderstood, but according to Jesus, also strangely blessed. Whatever side you are on, perhaps you have a moral duty to make every effort to understand the other. Unless we do, we cannot begin to help resolve this most intractable and dangerous of global problems.