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

Language

Politics

27 June 2025

5 min read

Our public discourse needs responsible rhetoric before it is too late

The right turn of phrase can turn a nation, the wrong one can destroy

Tom Dove

Tom has a PhD in Theology and works as a hospital physician.

A crowd of people stand in the side steps of the Lincoln Memorial

Easter services, Lincoln Memorial.

George Pflueger, via Unspash.

When was the last time a brilliant piece of rhetoric made the headlines?

“Empty rhetoric.”

“Form over function.”

“Sloganeering.”

These—and other accolades—are stock trade when it comes to the art of denouncing public discourse. Red flags are rightly waved in the face of baseless claims and insincere promises. Scroll through a news reel; open a newspaper: language far stronger in style than in substance is not hard to find.

Nowadays we are sensitive to these kinds of abuses of public platforms. When Donald Trump speaks of the ‘Great Big Beautiful Bill’ or Elon Musk of the ‘Big Ugly Bill’ we know the cogs at BBC Verify are likely to be turning. Fact-checking is an established trade.

Sometimes political turns of phrase are just careless, inadequately thought through. Granted, a politician’s public address is often put together at a pace. Time is so remarkably tight that phrasing and formulations are not interrogated as fully as they might be. (Krish Kandiah recently picked up the Prime Minister’s “island of strangers” line and its unfortunate resonance)

But of course, the critiques I’ve listed above are themselves sharply rhetorical. They are punchy. Not drawn-out logical deductions. They aim to make us sit upright and win us over. Or move us to a course of action.

So: is rhetoric the problem? No. Its misuse is the problem. This isn’t always clear. And it’s the reason why simply decrying “rhetoric” won’t get us very far.

I am sympathetic to the suspicion. When efficiency and pragmatism tower high among the canons of public discourse, it is easier to trade in polarising x versus y expressions. Being guarded in the face of such potent idiom is understandable.

And yet the most remarkable public discourses in human history have been rich in rhetoric.

Martin Luther King at the Lincoln Memorial: “I have a dream.”

Churchill in the House of Commons: “we shall fight them on the beaches.”

Lincoln’s Gettysburg address: “government of the people, by the people, for the people.”

All these speakers knew that bare understanding doesn’t typically move people to action. An impassioned speech, a plea to respond, or beautifully woven prose often serve as the tipping point for social engagement.

Which leads me to wonder, what if a suspicion of smart speech-making ends up stunting social engagement, rather than fostering it? Perhaps political discourse today has gone too far; perhaps rhetoric is beyond repair. And yet: abuse doesn’t mean there isn’t proper use. There is a better way.

When persuasive powers are uncoupled from sound argument, then rhetoric obscures understanding and has become irresponsible.

In the classical era, training in rhetoric was a prominent feature of an education. You might say it was the way to avoid the charge: “All substance, no style”. It was about turning a sound argument into an art form. For Aristotle, rhetoric was about making use of the tools of persuasion—substance with style. But skill in persuasion was not a virtue of itself; it never stood alone. As Roger Standing has reminded us, “the function of rhetorical skills was not to persuade in and of themselves.” Indeed, training in rhetoric was training in responsibility.

In his classic 1950s text Ethics of Rhetoric, Richard Weaver put his finger on this. He highlighted that “rhetoric passes from mere scientific demonstration of an idea to its relation to prudential conduct.” True rhetoric, then, is this: the art of lighting up the path that leads from sound logic to good action.

Today, it seems that when it comes to the rules of rhetoric, communicators are answerable to polls and popularity. These ends justify the means, which makes fancy formulations fair game. If style secures votes, then it’s a good job done. But this means the communicator has no real accountability for his or her language. Pragmatism is in the driving seat. In a sense, responsibility has been handed over to the hearer.

This is problematic. When persuasive powers are uncoupled from sound argument, then rhetoric obscures understanding and has become irresponsible. Language is no longer illuminating, but misleading. It is trading on falsehood, or perhaps half-truths, instead of magnifying what is true for the sake of what is good.

Take an example. In the recent parliamentary debate over amendments to the assisted dying bill, the proceedings opened with the claim that “if we do not vote to change the law, we are essentially saying that the status quo is acceptable.” I don’t for a moment doubt the good intent in this claim—securing the most compassionate care possible for terminally ill adults. But let it be said: no, those who do not advocate assisted dying are not “essentially” saying this. This claim is a non sequitur: the conclusion does not follow the premise. It is logically unsound.

Like many tools, the art of persuasion can be wielded carelessly; sometimes maliciously. But rhetoric-free public discourse would make for a colourless and lifeless thing indeed. What we need now is rhetoric that is responsible—responsible to what is true and responsible to good outcomes. These should not be split; as soon as they are, speech-making becomes sterile or hollow. I recently heard the neat phrase: “Some people reach your mind by going through the heart, and some people reach your heart by going through your mind.” Yes, as the Christian faith has always maintained: mind and heart belong together. Give us words that awaken both, like those once spoken by that obscure wandering rabbi, Jesus of Nazareth, in one of the most studied and penetrating speeches in human history:

Blessed are the poor in spirit, for theirs is the kingdom of heaven.

Blessed are those who mourn, for they will be comforted.

Blessed are the meek, for they will inherit the earth.

Blessed are those who hunger and thirst for righteousness, for they will be filled.

I pray for public discourse brimming with both substance and style. It might help lead us to better things.

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