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

Climate

Comment

Politics

22 September 2024

5 min read

Climate meets politics at UN summits, so who will save us?

It's that time of year when commitments to change are sought. Is there a different way to power the energy transition?

Julia Kendal

Juila is a writer and social justice advocate.

A fallen statute with tyre tracks over it lies on the steps to a government building, in a form of protest.

Climate protest, Berlin.

Nico Roicke on Unsplash.

We’re coming up to a tipping point: the autumn equinox, when the balance of light and dark shifts. For some, this season change still carries the possibility of September – new term, fresh notebook; for others, myself included, there’s more a feeling of ‘here we go again’ with the nights closing in and the hurtle to the end of another year.

On the global scale, it also kicks off the pattern of international summits and negotiations to drive progress on making this world, our world, a bit fairer, safer, and more hopeful. World leaders gather in New York for the United Nations (UN) General Assembly; then it won’t be long until the next UN Climate Summit (COP29) in Baku, swiftly followed by discussions in Busan to create a new UN Treaty to end plastic pollution. Perhaps that draws another sigh; here we go again.

But there’s something new this time on the agenda in New York: the UN’s Summit of the Future on 22-23 September. It is being touted as a ‘once-in-a-generation’ opportunity to forge a better way forward. Will this be the moment that saves not just us, but future generations and the natural world too?

A few years ago, I was involved in organising an event that brought together experts in sustainable development from science, government and civil society. To get the conversation going, we wrote this question on a flipchart: What will save us over the next decade? We asked people to cast their vote with a sticker, giving them just three options: government; society; technology.

As people gathered around, we noticed a general pattern emerging:

the scientists voted for government
the civil servants voted for society
people from civil society voted for technology

There seemed to be subtext to all this:

‘Who will save us?

Not me.’

I wonder if in that moment, the people voting – knowledgeable and connected, experts in their industries – were feeling the limits of their power.

When we brush up against our own limitations, it can be tempting to look elsewhere for reassurance. I find hope in a too-little-known story of change, a kind of David and Goliath story , that cuts across government, society and technology. A story that has seen leaders held to account, voices heard and literally billions of dollars shifted out of fossil fuels and into clean energy.

It might seem distant from our day to day lives, such wrangling over exact punctuation at global summits. But these commitments can have long-lasting influence.

People said it was impossible, because no one had ever done it before. For decades, the UK and other wealthy nations provided billions in taxpayers’ money for fossil fuel projects in other countries around the world. People’s taxes were spent on a gas plant in Mozambique, oil fields in Brazil, thereby fuelling the climate crisis and risking locking low-income countries into using fossil fuels for decades to come instead of investing in the clean energy transition.

This is a transition that has begun. In most places around the world, solar and wind are cheaper and more easily accessible than oil, gas or coal. Power is transformational; it fuels homes, schools and hospitals, it unlocks jobs, education and healthcare. And it’s getting to the point where there’s little reason it can’t be renewable.

With the technology getting there, it became time for the political will to shift too. So, a few years ago, a small group of campaigners came together to push for an end to this funding in the UK. They built relationships with MPs and civil servants, they got the media interested in this fairly niche issue, and they worked with the communities affected by UK-funded projects, coming with a straight-forward message that got to the heart of the injustice: stop funding fossil fuels overseas.

And it worked. In December 2020, the UK announced an end to all taxpayer support for overseas fossil fuel projects, the first high-income country to do this. But not the last. In the run up to the 2021 UN Climate Summit, campaigners and civil servants worked to get 38 more countries and large banks to make the same commitment to end funding for fossil fuels and shift it into renewable energy projects. With Norway and Australia joining at COP28 last year, that group now numbers 41, and represents over $28 billion a year that could be shifted from fossil fuels and into clean energy.

It’s not been plain sailing, and it’s not fully in the bag. For a few years, I got work alongside the incredible advocates at the frontline of this work. A few weeks ago, some of them published a new report which found good progress on the fossil fuels part of the pledge but much more work needed from governments on getting that money into the renewable energy projects that could be transformative for the 685 million people who currently don’t have access to electricity.

This story reminds me that ‘saving us’ isn’t a once and done thing. It’s bigger than that; something to be lived out, imperfectly, with others, over the years.

One of the hot topics at the Summit for the Future, is whether the leaders can agree to transition away from fossil fuels in a new ‘Pact for the Future’, echoing language that was fought for, weakened, then mostly put back into the final commitment made at COP28 last year. (This counts as a high stakes drama in the climate policy world). It might seem distant from our day to day lives, such wrangling over exact punctuation at global summits. But these commitments can have long-lasting influence. For nearly 80 years, the Universal Declaration of Human Rights has been protecting people – or showing the gap when their rights are being violated.

And really, this isn’t just about words, it’s about power.

Part of the problem with our question on that flipchart was that it divorced people and opportunities, rather than bringing them together. The best way of driving change is to build collective power, holding each other and our decision-makers to account.

Perhaps thinking of the future brings more fear than hope. But this story reminds me that ‘saving us’ isn’t a once and done thing. It’s bigger than that; something to be lived out, imperfectly, with others, over the years. And lived out with God. This is a partnership that he invites us into: to join in his work of seeing a world full of potential being nurtured and restored. We might not see the whole change we hope for, but sometimes we’ll get to see the scales tip.

The energy transition has begun – but it’ll take the collective influence of a movement of people to ensure that it’s fast, fair and serves those who need it most. With a big gap remaining between the finance needed and the finance pledged, all eyes are on this year's COP29 in Baku to see tangible progress.

Here we go again.