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

America

Conspiracy theory

Culture

Politics

18 September 2024

5 min read

US election: the primal stories trumping facts

Projections and polls cannot capture the power of stories shaping identity.

Jared Stacy

Jared holds a Theological Ethics PhD from the University of Aberdeen. His research focuses conspiracy theory, politics, and evangelicalism.

a map depicts US states coloured red and blue.

538 election prediction map.

ABC News.

Washington D.C. — Election throes in America are intensifying while citizens prepare to cast their votes. The last week alone has been something like a whirlwind, not to mention the entire campaign itself.

Last week, Americans tuned into the first and possibly final Presidential debate between Trump and Harris. On the heels of the debate came a flurry of propaganda leveled by JD Vance (and promoted by Trump) against Haitian migrant communities in Ohio. These claims resulted in bomb threats and school closures.

And to wrap up the week, a second assassination attempt on Donald Trump in nearly as many months. Trump and his campaign, quicker and more direct that the first attempt, quickly cast the blame towards Democrats, specifically for what they see as violent rhetoric in describing Trump as a “threat to democracy.” Trump meanwhile continues to campaign on threats and claims of election fraud, refusing to signal he’d accept the certified results of the election in the event he loses.

That’s just another week in an unpredictable American presidential election.

Americans are besieged, all of us, by a throng of pollsters, partisans, and pundits. Each trying to ride the raging bull of the election cycle.

And life goes on. For now, in this time, in my small corner of American life, I find there is this mixture of exhausted apathy and existential rage. In view of the spectacle, there’s a general exasperation of “what will happen next?” But more personally, dispersed on social media, is the existential zeal and dread—“we” have to defeat “them!”

The danger of this mixture is twofold. Just as odd as it is potent. It is also combustible. And just as it can lay dormant; it can also be summoned by a mere spark.

Americans are besieged, all of us, by a throng of pollsters, partisans, and pundits. Each trying to ride the raging bull of the election cycle with predictions and projections. Some offer prayer.

I listen in on conservative Christian talk radio. Prayers offered on air for God to intervene. What follows is a litany of slogans— “secure our borders” and “defend life” and “the economy” — and of course prayers for the salvation of those who think differently.

Then, there’s more daring outrage merchants with deep pockets. Those who try to shift the election through nefarious means. Like the case of Tenet Media, a media network of right-wing American podcasters who were recently indicted by the Justice Department for receiving Russian funds through fronted companies.

It seems to me that the heart of the matter in the midst of this election, deeper than policy and beyond the spectacle, is that none of us are entirely sure what reality another person inhabits.

A new study published last week found that most registered Republicans (at 67 per cent) trust the Trump campaign as their primary source for election information. Trump’s word, for nearly three quarters of his party, is given more authority than government certification, media-based news, or local news.

This raises the possibility that, in 50-some-odd days, if Trump refuses to concede, if he repeats claims of election fraud, his base seems ready and willing to believe it.

Our social and political worlds have been set on fire not for want of facts but by stories which overpower fact with meaning.

Alongside the debates about policy, the propaganda that stokes division and dehumanizes migrant communities, is a deeper crisis of source authority. Of not just “facts” but truth, of meaning, of reality.

The study revealed that most Americans signal they tend to trust information that comes from “data” and “facts.” But oddly enough, nothing about that statement seems to accord with the on the ground reality of America’s social fabric.

We should know by now: facts have never been enough.

100 years ago, as novelist Rebecca West reflected on the chaotic series of events that sparked World War I, she admitted, “I shall never be able to understand how it happened. It is not that there are too few facts available, but that there are too many.”

What seems “real” for many Americans is not (and perhaps has never been) rooted entirely in the all-powerful “fact.” Our social and political worlds have been set on fire not for want of facts but by stories which overpower fact with meaning. These stories are primal. They’re the kind which create identities and bind communities. They are rich in meaning and so prove entirely immune to fact-checking operations. Source authority has no power apart from primal stories. And though projections and polls tend to focus on the data, they cannot capture the power of stories which create identity and contain community. This is the stuff the vote is made of, too.

This past week, JD Vance defended his propaganda in the form of conspiracy theories of Haitian migrants eating pets by telling CNN, “If I have to create stories so that the American media actually pays attention to the suffering of the American people, then that's what I'm going to do.”

Ends-justifies-means has always been ascendant in politics. Nobody is arguing that MAGA invented political expediency. But this election is careening towards deep waters which we would do well to avoid.

“Propaganda is a means to an end,” said Reich Minister of Propaganda Joseph Goebbels in 1934 before an audience at Nuremberg, “…it provides the background music...[it] miraculously makes the unpopular popular, enabling even a government’s most difficult decisions to secure the resolute support of the people.”

I do not know what the next 50 days will hold. I remain deeply concerned that the word of Trump aspires to assume an authority which sees democracy as a meddling imposition in one man’s destiny. But I do know that none of this is fated. As Augustine observed during the throes of Rome’s collapse: “Bad times! Hard times!” this is what they are saying. But let us live well and the times shall be well. We are the times. Such as we are, such are the times.

May it be so.