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.

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Economics

Morality

Politics

27 September 2024

4 min read

The Conservative Party needs a moral reset

A party member recalls that Adam Smith was a moral philosopher as well as an economist.

Jean Kabasomi

Jean is a consultant working with financial and Christian organisations. She also writes and broadcasts.

A statue of a Georgian man looks to the left.

Adam Smith, looking right to left.

Glasgow University.

The election of a new government in the United Kingdom has felt like an opportunity to fix some of the daily challenges faced by the people of these isles. As a member of the Conservative Party, it also presents the chance for those of us who are Conservatives to take stock of what it means to be conservative and how best that definition can serve the people of the UK in a way that benefits the whole and not just specific parts.

Those who follow the internal machinations of the Conservative Party will know that the battle for a new leader has already begun. For the most part, it has focused on whether the Party needs to move to the right to combat the offering by the new kids on the block – Reform, or to the centre in order to block the leaking Shire vote that shifted to the Liberal Democrats. I want to propose a different approach.

For years as I was growing up, probably influenced by the media and how it presents politics, I assumed that the idea of a minimum wage was a socialist idea or what we might today describe as progressive politics. Things changed, when I studied the history and influence of Christian thought on Western economics, as part of a Masters in Biblical Studies at the University of Edinburgh.

Adam Smith is the father of modern capitalism and hero to many conservatives. His foundational text, The Wealth of Nations, was on the reading list. Prior to these studies, I had heard and seen many conservative commentators use that text to support their claims around small government. I had also seen liberal commentators vilify his work for being the source of our broken Western systems. Many claimed that it was the basis for the economic thought and principles of Hayek and Friedman, the prominent economists who influenced the policies of the Thatcher government in the UK and the Reagan government in the US.

It tells us that our dogmatic positions should not prevent us from focusing on what is in the best interest of the people that politics and economics are supposed to serve.

When I read The Wealth of Nations for myself, I was shocked. I couldn’t believe how much of what he had actually said was ignored or had been misrepresented. Reading it for myself changed my assumptions and my learned narrative on capitalism. One of my greatest surprises was that Smith held what I had known to be a socialist policy, the idea of a minimum wage. To him it was such a fundamental truth that it was only briefly mentioned. Perhaps, that’s the reason so many people miss it.

Another shock was discovering that Adam Smith wrote about the place of government in regulating large corporations. For Smith, the wealth of large corporations was to be invested back into the areas from which the company was built. Jobs were to be kept local so that as many people as possible in society benefited from the wealth generated. Smith outlined that government regulation should prevent large corporations from moving their manufacturing operations to cheaper international locations to reduce costs and sidestep local communities.

Adam Smith, the father of capitalism – a protectionist and believer in the rights of workers! But what has this got to do with a discussion about the Conservative Party? It tells us that policies that do not always favour corporations but help workers or local communities are not unnecessarily anti-capitalist and by extension unconservative. It also tells us that our dogmatic positions should not prevent us from focusing on what is in the best interest of the people that politics and economics are supposed to serve.

My party needs to move away from policies that are focused on ideological battles and economics rooted in abstract ideals. And, instead, look to policies that will tangibly help everyday people. Or put differently, the party needs to move away from Oxford Union politics (I have nothing against the Union, I am a lifelong member!) and focus on real-world grown-up politics that improve the lives of the ‘many not the few’!

Lord Cameron tried to move the party to a position often dubbed Compassionate Conservativism. In fact, the origins of capitalism have long been connected to moral principles. Adam Smith not only wrote The Wealth of Nations but also considered issues around morality in his The Theory of Moral Sentiments. For a government to govern effectively and an opposition to oppose properly, morality and the interests of the many must be reflected in policy. And in my humble opinion, it is not unconservative to do so.