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.

Explainer

Belief

Climate

Comment

Sustainability

13 September 2024

7 min read

Living sustainably doesn’t have to be a burden, here’s the case for action

How not to get hot and bothered about climate change.

Barnabas Aspray

Barnabas Aspray is Assistant Professor of Systematic Theology at St Mary’s Seminary and University.

A protester holds up a green sign reading: 'It's hard to be green. Kermit'.

Markus Spiske on Unsplash.

The fundamental tenets of Christianity show why Christians are called to love not just one another but all created things.

1. God is love.

2. God created everything.

Therefore, God loves everything he created.

3. God appointed humanity as the guardians of creation.

Therefore, a fundamental part of our identity and calling as human beings is to protect and sustain all that God created.

This lies at the basis of everything Christians believe and do. But a case can be made that is more basic still because it appeals, not to anything distinctively Christian, but to natural human wisdom. The climate crisis is not a Christian crisis. It’s a crisis for everyone who cares about their future and that of our planet. The climate crisis may be something unprecedented in the history of humanity, but the principles that are needed to resolve it are not new at all. Sustainability is not a new or particularly abstruse idea. It is something everyone understands as basic common sense. If I cut down trees faster than they can grow, I won’t be able to do that forever. One day I will cut down the last tree and then there won’t be any more trees, ever again. If I catch fish faster than they can reproduce, then one day I will catch the last fish and then won’t be able to catch any more ever again.

But it’s not only about foresters and fishermen. Since the dawn of humanity, we have been living sustainably – wisely preserving resources and using only what we can replace, so that we and our descendants can continue to live. This applies to everyone regardless of their profession. All of us, if we spend more money than we earn, are living in a way that cannot last for long. If we use resources at a faster rate than we can replenish them, we will run into trouble at some point in the future. Every person possessed of reason and common sense knows this intuitively without having to be taught it. Only someone seriously deluded, foolish, or with some kind of mental health problem fails to understand the need for sustainability in order to have any kind of future at all, let alone a pleasant future.

The call to live sustainably can lead us to feel burdened by a permanent sense of guilt, a feeling that we ought to be doing more than we are...

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We are burning fossil fuels at hundreds of times the rate they can be produced. We are producing plastics that cannot be recycled, meaning we have to dump them in landfills that are growing all the time. We are pouring carbon dioxide into the air faster than anyone can take it out. All of these things mean that there is a time limit on the kind of lifestyles we are all leading now. If we carry on in this way, then one day we will cross a line from which there is no returning. As Mark Scarlata has pointed out, the solution cannot be technological. Even if we find a way to balance carbon outputs with inputs, we are only kicking the can further down the road. Our inability to live within our means will simply resurface somewhere else later on. The problem is spiritual, not technical.

Everyone understands this at some level even if it’s the kind of truth from which we prefer to avert our eyes. The harder problem is to understand why this basic common sense isn’t proving effective. Why are we living collectively in a way that only a foolish or insane person would live, when most of us taken by ourselves are neither foolish or insane?

The problem, at least in part, is that we are all entangled in systems that make it very hard for us to live sustainably. If I am an ordinary Brit living in an ordinary town or city, and I need to buy toothbrushes or nappies or cucumbers or strawberries, I go to the local supermarket: and the only options available are made of plastic or wrapped in plastic that will not decompose for 500 years, and often brought here from the other side of the world using huge amounts of carbon emissions. Most of us are busy people with limited financial resources. We don’t have the time to find sustainable alternatives and often they are too expensive even if we can find them. The societal structures that we live in limit the choices we have. The call to live sustainably can lead us to feel burdened by a permanent sense of guilt, a feeling that we ought to be doing more than we are, but also an inability to see how we could be doing more given all the pressures, needs and constraints on our time and money.

Christians do not naively believe that God will sweep in and fix everything if we just wait. That would be to deny our responsibility, and it is not what hope means.

We are all culprits in part, since we all contribute to non-sustainable living. But we are also partly victims of forces beyond our control, large cultural forces that shape and determine our actions more than we can imagine. We have very little power over those structural forces and currently things do not look good. Common sense principles aren’t working. The climate crisis is only getting worse. So, what do we do?

It is at this point that Christianity has something special to offer to the problem.

First, Christians are never called to be defeatist or to throw in the towel. This is because we are called to an enormous hope, a hope that surpasses understanding, a hope that the world cannot understand because it stands over against all the odds and all the possibilities. This hope is rooted in the conviction that our God is God Almighty, that he has not abandoned his creation, and that he has power to save. He is a saviour. He is the God of our salvation. This is the God we believe in. The climate crisis may look bleak right now, but Christians need never despair or become indifferent. If we do our small part, we can trust that God is in control of what is out of our control.

Secondly, Christians believe that every human being is a free agent with the capacity to choose how he or she will act. Our freedom may be limited by the societal structures that shape and constrain our choices, but it is not destroyed. We can still make choices within those limits to buy and live more sustainably – anything from choosing a holiday destination within driving distance, to giving up beef (by far the worst food for carbon emissions). There is something all of us can do.

Thirdly, Christians believe in a God who transforms hearts and lives, winning them to the power of the gospel and to a new way of living that is free of the shackles that this world – the structures of society – puts on us. This transformation is slow – slower than we would like it to be sometimes. We feel the shackles still gripping us at times. We are not expected to change everything all at once, to become holy overnight. Nevertheless, God gives us the power to change our lives, and to become part of the solution rather than part of the problem. The way towards sustainable living is not to try to change everything at once, but to ask: what one thing can I change in my daily lifestyle that would make it more sustainable? And then once we’ve mastered that and integrated it so we no longer even think about it and it’s just a default, then we can ask: what’s the next thing I can do? All of a sudden what looks like an unimaginable height of transformation, when it is broken down, becomes a series of manageable steps.

Even if we do everything in our power, we cannot by ourselves avert a possible catastrophe. We are small players in a big game. Christians do not naively believe that God will sweep in and fix everything if we just wait. That would be to deny our responsibility, and it is not what hope means. Hope means the opposite: that we continue to fight to avert climate disaster even when it seems hopeless. Christians are called to be part of the solution rather than part of the problem. We are called to live in such a way that, if catastrophe comes, it won’t be because of us – to live in hope that our actions are meaningful and worthwhile and that we are in the hands of a God who is far more powerful than the most powerful forces in this world.