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

Character

Culture

Leading

Virtues

19 September 2024

6 min read

What is Putin thinking? And how would you know?

The self-centeredness of modern culture is antithetical to strategic thinking.

Emerson Csorba

Emerson Csorba works in deep tech, following experience in geopolitics and energy.

Preisdent Putin stands behind a lectern with a gold door and Russian flag behind him.

What is Putin thinking?

In a world of Google Maps when walking on city streets, or of Waze when driving, it is difficult to ever become lost.

The AI algorithm provides us with the shortest route to our destination, adjusting whenever we make the wrong turn. We do not need to think for ourselves, technology instead showing the way forward.

But there are times where it is possible to get lost. This happens less in a city with its clearly set-out streets, and more so when taking the wrong turn in open expanses: hiking in the mountains, traversing farmers’ fields or while navigating at sea. In each of these situations, a miscalculation may lead to peril.

It is in these situations that we must carefully think through our steps, determining how to proceed, or whether to turn back. Often, these situations are ambiguous, the right way forward unclear.

Much of life – perhaps more than we wish to acknowledge – is like this, more akin to a walk across an open field with multiple possible routes forward, than a technology-enabled walk through a city.

When making important decisions, our grasp of a given situation, of others’ intentions and motives, and the networks facilitating and constraining action, are less evident than we may initially think.

This acknowledgement of uncertainty is no reason for delay, but rather a basis for careful deliberation in determining what to do, and how to proceed. It is necessary if we are to pursue what we believe is right, in a manner that may produce positive results.

In a recent interview with the BBC Newscast podcast, University of Durham Chancellor Dr Fiona Hill – who previously served as White House National Security Council Senior Director for European and Russian Affairs, and currently as Co-Lead of the UK’s Strategic Defence Review – provides listeners with a powerful reminder on how to proceed within ambiguous situations, especially in navigating the choppy seas, or rocky terrains, of human relationships.

Strategic empathy requires self-restraint when natural impulses urge a person to make rapid conclusions about the reality of a given situation – the default human tendency.

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Dr Hill uses the term “strategic empathy” to consider how the political West might proceed in its relationship with Russia, and specifically with Vladimir Putin.

Strategic empathy is a serious commitment to understanding how another person thinks, considering their worldview, their key sources of information (in other words, their main three or four advisors, who have a person’s ear), and other emotional considerations that underpin decision-making.

It is much more than just putting oneself in other’s shoes, as is often said about empathy. The approach is one of realism, suspending judgment based on self-protective or self-aggrandising illusions, in favour of what is actually the case.

In the case of Putin, Dr Hill helpfully reminds listeners that his worldview is drastically different than that of Westerners, and that significant intellectual effort (and specifically, intellectual humility in setting aside one’s own default frames of reference) is necessary to consider decisions from Putin’s perspective, and so make the right decisions from ours.

Technology is here an assistant but not a cure-all. Whereas AI might – based on a gathering of all possible publicly available information written by and about a particular person – help to predict a person’s next move, this prediction is imperfect at best.

There are underlying factors – perhaps a deeply engrained sense of historical grievance and resentment in the case of Putin – that shapes another’s action and that can scarcely be picked up through initial conversation. These factors may not make sense from our perspectives, or be logical, but they exist and must be treated seriously.

This empathy is strategic, because effective strategy is the “How?” of any mission. Whereas a person’s or organisation’s mission, vocation or purpose (all words that can be used relatively interchangeably) is the “Why?” of a pursuit, strategy is the “How?” which itself consists of the questions “Who?” “What?” “When?” and “Where?”

To understand how to act strategically requires a prior effective assessment of reality. This requires going beyond what others say, our initial perception of a situation, any haughty beliefs that we simply know what is happening, or even the assessments of supposedly well-connected and expert contacts.

Dr Hill’s strategic empathy is an appeal to listeners to ask questions – digging as much as possible – to arrive at an assessment that approximates reality to the greatest degree possible. This exercise might be aided by AI, but it is at its heart a human endeavour.

Strategic empathy requires self-restraint when natural impulses urge a person to make rapid conclusions about the reality of a given situation – the default human tendency. The persistent asking of questions is difficult – requiring mental, emotional and intellectual endurance.

There is considerable wisdom in Dr Hill’s reflections on strategic empathy, which extend well beyond the fields of intelligence, geopolitics or defence. The idea of strategic empathy helps show us that in much of modern culture – which glorifies the self, individuals putting their wants, needs and desires before those of others – developing strategy is very difficult.

The key then, when deliberating on potential right courses of action in ambiguous situations, is to not begin believing that the right way is clear. It rarely is.

Why is this the case? When popular culture favours phrases such as “You do you,” the you becomes a barrier to asking questions, with some aloofness to the situation, necessary for understanding how another thinks. People are encouraged to focus on themselves at the expense of others, and so fail to understand others’ worldviews and ways of operating.

Simply put, the self-centeredness of modern culture is antithetical to strategy. It impedes deliberation, which involves patience in the gradual formation of purpose for action. It wages war against the considered politics or statesmanship that many want to see return. In place of this is crisis or catastrophe, in which self-focus leads to clashes with others that could otherwise be avoided or worked through carefully.

The Biblical story of the serpent in the garden is another vantage point for the idea of strategic empathy. Soon after Adam and Eve eat the apple in the garden and become “like gods, knowing good and evil,” God searches for them and asks “Where are you?”

It is right after individuals try to become the judges of good and evil – “like gods,” that Adam and Eve find themselves lost: God’s “Where are you?”

Put differently, when a person is convinced they are right, but without asking questions, they make mistakes, they likely suffer unnecessarily because of this, and then become anchorless – the “Where are you?”

This applies to countries as much as it does to people: the more they moralize, seeking to become the judges of good and evil in a complex geopolitical landscape, the more they drift from their sense of purpose.

The key then, when deliberating on potential right courses of action in ambiguous situations, is to not begin believing that the right way is clear. It rarely is. A belief in evident rightness often leads to error, whereas the ability to suspend such judgment helps reveal – often gradually – the right path forward.

The strategic empathy approach requires both assertiveness – in asking good questions and maintaining persistence in doing so – and self-restraint in the face of believing that the right answer is clear.

The glue between assertiveness on the one hand and restraint on the other is faith, which helps a person to move forward in a trusting manner, but without exerting oneself so much so that they become the centre of the situation.

So, while Google Maps, Waze or other technologies might be at our disposal in our travels, both real and metaphorical, these technologies only get us so far.

The right way forward is seldom initially clear when navigating ambiguous situations, the frequency and stakes of which increase as we embark boldly – with faith – on the adventure of life.

Dr Hill’s strategic empathy – asking questions, listening carefully, suspending a self of sense, seriously considering diverging worldviews, and adjusting as necessary – helps us to achieve the understanding and direction we need.

Indeed, this approach is fundamental to a more effective and resilient political West. It is necessary for sounder deliberation, better strategy and statesmanship, in an increasingly ambiguous world.