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

Politics

Virtues

27 September 2024

8 min read

The emerging frontier: renewing courage in geopolitics

Narcissistic moralising needs to stop, and we can learn from Churchill too.

Emerson Csorba and Gal Treger

Emerson writes on geopolitics. Gal is a tech investor.

Military personnel, wearing camoflague uniform crowd round a computer monitor.

U.S. Space Force guardians assess a threat.

U.S. Space Force.

In August 1939, the Polish poet Kazimierz Wierzyński reflected on a “Peaceful bliss which had become Europe’s chloroform.” Yet, then as now, crises shake us from moments of calm, especially when we abandon vigilance. We let our guards down, nonchalance replacing serious deliberation toward action.

A shroud of darkness has descended on the world over recent years, with new conflicts emerging just as – or perhaps because – democratic populations turn inward. These conflicts – whether the Russia-Ukraine War, the Israel-Gaza War, or the US-UK led battles in the Red Sea – demonstrate the courage of peoples sacrificing for their nations, families, histories, and traditions.

Yet, in much of the political West, narcissism – rather than courage – has become the focal point of our culture.

Christopher Lasch describes this narcissism in The Culture of Narcissism: American Life in an Age of Diminishing Expectations as a conceit of the present. Lasch notes that we have become a consumer society focused on individual self-absorption that leads to present-focus, sense of isolation, and disconnection from history.

The psychoanalyst Erich Fromm argues in The Heart of Man: Its Genius for Good and Evil that narcissism is an attachment to “self-image,” which “distorts rational judgment.” Yet, Fromm later reflects “If the feeling which the Greek poet expressed in Antigone’s words, ‘There is nothing more wonderful than man,’ could become an experience shared by all, certainly a great step forward would have been taken.”

This wonder of man is in the freedom to act in a world that is yet to be determined.

This is a position of “deep faith.” It encourages full participation in the world, affirming the self through action, though always in relation to something much greater.

The philosopher and theologian Paul Tillich similarly states “this is just what participation means: being a part of something from which one is, at the same time, separate. Literally, participation means ‘taking part,’ in the sense of ‘sharing’ or ‘having in common.’” We play, as legendary Notre Dame football coach Knute Rockne once said, "For everyone that came before us, and everyone that will come after us."

If common history is needed as our foundation for current action in geopolitics, to what then might we turn?

We propose a refocusing and modern renewal of alliances underpinned by Winston Churchill’s A History of the English-Speaking Peoples, a project he initiated in the early 1930s as the threats of Nazism and Fascism had taken centre stage.

This refocusing reprioritises courage in geopolitics, maintaining the light amid descending darkness. It is badly needed given the modern tendency to look inward rather than to sources of value outside of the self.

This is a pathway to vigilance in anticipation of the thief in the night, who may arrive at an unexpected hour.

Churchill – recently demonised by influential conspiracy theorists – emphasises the common cultural and political heritage of the English-Speaking Peoples, including the rule of law, individual rights and parliamentary democracy, which shaped the modern world.

Churchill reminds us of the global influence of English-Speaking Peoples in spreading democratic ideals and governance structures across the world, believing that the global spread of these ideas was instrumental in shaping modern life. He underscores the unity of the English-Speaking Peoples in facing global challenges, particularly in the context of the World War he foresaw. And he viewed the cooperation between the UK, the US, and other Allied nations as crucial to the survival of freedom and democracy.

It is important, now as much as ever, that we remind ourselves of Churchill’s wise words, building on them to address with courage the challenges of our present times.

Specifically, we must adapt Churchill’s emphasis on the English-Speaking Peoples to a focus on nations working at the frontiers of Western civilisation to resist rising darkness which seeks to corrupt the good. Ones not necessarily actually speaking English too.

Building on these unique and complementary strengths, these agile nations united as upholders of the values of English-Speaking Peoples should reindustrialize, rearm, redraft and recommit to a common goal in a world of increasing geopolitical conflict.

The sharing of expertise and overall close collaboration between these agile nations can facilitate rapid preparation for conflict at any moment, proactively addressing Wierzyński's dangerous “peaceful bliss.”

In other words, this is a pathway to vigilance in anticipation of the thief in the night, who may arrive at an unexpected hour.

Renewed partnership is necessary between these nations. There is a need for these nations to re-assert their historical courage, underpinned by vital modern capabilities.

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Alongside the United States as the focal point, these nations are Canada on the Arctic frontier; the United Kingdom as a Northern frontier; Poland as the Eastern frontier; Israel as the Southeastern frontier towards the Eurasian landmass, and Australia, with its recent experiences confronting neighbour China, on the Far East frontier.

Each of these nations serves as a regional center of power and influence: Canada in the Arctic and Atlantic; the US into the Caribbean and broader Latin America; Israel in the Middle East with the Abraham Accords and North Africa; Poland into Central and Eastern Europe, and Australia in the Indo-Pacific. Each of these nations possesses vital agility, given their small geographical sizes or populations.

These frontier nations respond to United States CIA Director William Burns’ 2023 Ditchley Lecture, in which he focused on “[hedging middle power countries who] see little benefit and lots of risk in monogamous geopolitical relationships. Instead, we’re likely to see more countries pursue more open relationships than we were accustomed to over several post-Cold War decades of unipolarity.” The focus here is courage with a long-term view, building a frontier-focused alliance rather than seeking relations based on short-term material interest only.

In this frontier model, it is currently Israel demonstrating the courage to uphold the values captured in Churchill’s account of the English-Speaking Peoples. Hamas’ brutal October 7th attack was predicated on the notion that over the last decades, Israel transformed into a consumer society, focused on short-term economic incentives and leisure pursuits. Israel provides technology and experience in fighting modern wars of various types, as well as persistence and proactiveness that other nations must quickly recover.

Canada is historically a frontier nation of courage, reflected for instance in its contributions to WWI and WWII victories, as well as in the often-quiet contributions that Canadians make to peacekeeping efforts across the globe. But Canada can take bolder action, given its strategic Northern location and proximity to the Arctic, with its vast natural resources including critical minerals supply and its vast freshwater reserves. It can become a more influential global player amid trade wars, helping reduce dependence on Chinese resources.

The United Kingdom’s combination of common law, property rights, financial markets and freedom of the press are important strengths. As Nigel Biggar finds in his Colonialism: A Moral Reckoning, the UK has historically championed free markets generating economic opportunities for diverse peoples; established peace where internal strife previously existed, protected the rural poor from wicked landlords, and provided civil service and judiciary systems to reduce corruption.

Poland, as noted by Radoslaw Sikorski in a recent speech, shares with the United Kingdom “the same strategic vision. It is based on the fundamental assumption that international law is the guardian of peace and stability.” Poland also “consistently supports close, comprehensive cooperation between the UK and the EU’s security and defence frameworks” with continued focus on strengthening its military capabilities. And, of course, Poland is keenly aware of the threat of war which which is ever-present on its border.

Australia has, over the last decade, demonstrated evident success in facing the threat of China on its doorstep, this ever-present threat producing a group of leaders across government, private and media sectors that are as sharp, worldly and realist in nature as any in the Commonwealth.

Renewed partnership is necessary between these nations. There is a need for these nations to re-assert their historical courage, underpinned by vital modern capabilities. C.S. Lewis, in his famous Screwtape Letters, shows that “courage is not simply one of the virtues, but the form of every virtue at the testing point, which means, at the point of highest reality.” Each of these frontier nations has historically demonstrated success in the face of testing.

Our focus cannot be narcissistic moralising – too often the case in today’s geopolitics – which is the product of the serpent’s advice in the Garden of Eden, in which our eyes will be opened as we “become as gods knowing good and evil.” We must not allow others to twist our sense of history, such that we begin to exalt ourselves in the present moment rather than adopting attitudes of service, sacrifice and worship of that which is unfathomably greater and farther-reaching.

Instead, it must be – as we have seen with Churchill, and as described by Dietrich Bonhoeffer in his incredible commentary on the story of the Garden of Eden, to act.

As Bonhoeffer writes, “If the Holy Scripture insists with such great urgency on doing, that is because it wishes to take away from man every possibility of self-justification before God on the basis of his own knowledge of good and evil… The error of the Pharisees, therefore, did not lie in their extremely strict insistence on the necessity for action, but rather in their failure to act. ‘They say, and do not do it.’”

The frontier model we propose facilitates such action, prepared with the necessary capabilities and coordination for the considerable challenges before us.

We must remember that to participate in the world with deep faith – courage – has been and always will be the basis for human freedom.

Indeed, this is the task of the nations: united by the common heritage of English-Speaking Peoples, acting with faith in the good, always at the frontier.