Article
Assisted dying
Comment
Politics
7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

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. 

Essay
Comment
Community
Identity
Politics
8 min read

The country needs fixing, here’s where to start

Turning back the clock, closing the gates, and putting up more flags, is not the answer
A commemorative blue plaque on a a wall is smashed to pieces
Julian Hochgesang on Unsplash.

This is the third in a series of articles clustered around the ideas of constitutionalism, Christianity and national identity. The first article set out the case for a new written constitution in order to protect against the authoritarian reactionary populism that threatens to undermine democratic norms and institutions. The second article made a distinction between England’s ‘metaphysical’ constitution and its ‘mechanical’ constitution – arguing that the former is in need of restoration, and the latter in need of thorough reform.  

This article concludes with a plea for peace and unity. There is not much, in this increasingly febrile and polarised political climate, that left and right agree upon. Who is responsible for the mess we are in: the Romanians or the Etonians? Against whom should we direct our ire: the people in small boats in the Channel, or the people in big yachts in the Cayman Islands? Was Thatcher a hero or a villain? Was the purity of Brexit bliss betrayed by scheming Remoaners, or was leaving the European Union always going to be a disaster? 

What we can agree upon, however, is that something is deeply broken. While we might disagree on the causes and the solutions, the unavoidable evidence of brokenness is before our eyes. In every area of daily life, things are – to use the most fitting vernacular expression – ‘a bit pants’. Perhaps things are not utterly dire, in the way that much of somewhere like Sudan or Burma is utterly dire, but they are nevertheless far from the standard that one might reasonably expect from the rich, first world, country we still claim to be.  

Park life 

Go, for example, to your local park, if there is one. Observe the broken glass, the graffiti, the used condoms, the discarded drug paraphernalia, the joyless air of bleak menace in a place that should be a happy sanctuary for children and families. If that description does not match your experience, perhaps you are one of the lucky ones, who lives in a good area – but many of your fellows, in dull decaying provincial towns, are much less fortunate.  

Parks are just one manifestation of a land in the doldrums. One might just as well point to the fact that since privatisation water companies have not built any new reservoirs, or to uncollected rubbish piling up in the streets of Birmingham, or to the difficulty of getting an NHS dental appointment. Everything is tired, run down, threadbare, falling apart.  

Those in charge, nationally and locally, are stretched between the irreconcilable demands of expanding needs and tight budgets. Engulfed by short-term crisis-management, they lack the ability to look up, grab the situation by the horns, and bring about the fundamental, structural and systematic change that is needed to actually fix things.  

The decay is evident, too, in society at large. Employment, for those who can get it, is characterised by low wages and precarity. Housing costs are absurd. People at all levels have become exhausted, demoralised, bored and lacklustre, locked in an ‘overwhelm paralysis’. The public mood has become despondent, cynical, ineffectually angry, but also frightened. Many are grimly hanging on, just going through the motions to the minimal extent necessary to endure the week, and afford the month. Even basic civility and politeness have worn thin.  

This is a far cry from a ‘Land of hope and glory’. Indeed, if one were to take honest stock of things, one might conclude that we live in a state where there is none righteous, and where all have sinned and fallen short of the glory of God.  

Cobwebbed constitution 

In making this sudden metaphysical turn – jumping from the decay, despondency and desperation evident around us, to the realm of the spirit – I do not wish for a moment to minimise the importance of such mundane human affairs as ideologies and policies. What government does and does not do, and what law allows or prohibits, matters. It should be no surprise that if governments leave undone those things which they ought to have done, and do those things which they ought not to have done, then there will be, at the end, ‘no health in us’.  

Still less would I wish to neglect the role of institutions and structures – and, ultimately, the constitution itself. The woes we experience, in terms of bad policy and poor execution, are largely the result of an ill-constituted state. The words of Tom Paine (a man ill-remembered by history, but one of the few Englishmen to have understood the centrality of constitutional matters) are as true today as when he penned them more than two centuries ago:  

‘For want of a constitution in England to restrain and regulate the wild impulse of power, many of the laws are irrational and tyrannical, and the administration of them vague and problematical.’  

When it comes to mending a country in decline, the first thing to do is to make sure the constitution is sound, and that the institutions of democracy and governance work as they should. Behind all the policy and governance failures, of both Conservatives and Labour, lies the fact that we are governed by the cobwebbed remains of a once mighty commercial imperial state, now hollowed out by neoliberalism, without any clear ethical principles to direct or sustain it. To expect good outcomes from such an ill-constituted state would be as absurd as expecting to gather figs from thorns, or grapes from briers. 

We might even put it in these terms: Every good constitution brings forth good government; but a corrupt constitution brings forth evil government. A good constitution cannot bring forth evil government, neither can a corrupt constitution bring forth good government. 

Constitutional renovation has therefore become a precondition for the restoration of the legitimacy, credibility, authority, and moral integrity of the state, as well as for the health, well-being, and prosperity of the people. This calls for quite a different project of national renewal from that offered by offered by the parties of the reactionary right. Simply turning back the clock, closing the gates, and putting up more flags, is not the answer.  

Governo largo 

The centrepiece of a national renewal project should be constitutional: to create a truly ‘public state’ – a democratic state founded upon, oriented towards, and capable of serving, the common good. Tend to that tree, water its constitutional roots, and the fruits will follow.  

Again, Paine tells us what the fruits of that good tree are, and therefore how to recognise when the constitutional tree is healthy:  

‘When it shall be said in any country in the world, my poor are happy; neither ignorance nor distress is to be found among them; my jails are empty of prisoners, my streets of beggars; the aged are not in want, the taxes are not oppressive; the rational world is my friend, because I am the friend of its happiness: when these things can be said, then may that country boast its constitution and its government.’ 

This is little more than a restatement of the basic Aristotelean distinction between good and bad government. Good government (the well-constituted state, or ‘polity’) governs in the public interest, for the common good, while all forms of bad government – tyranny, oligarchy and populism – govern in the private interests of the rulers, perverting public power for personal gain. 

The renaissance Italian statesman, Francesco Guicciardini, highlighted this distinction in clearer, more binary terms. He contrasted the ‘governo largo’ with the ‘governo stretto’. A governo largo is a wide, open, broad-based government, in which power is broadly shared and publicly accountable, so that public life is centred upon public needs. It is system of government not only by and of the people, but also for the people. ‘Governo stretto’, in contrast, is a narrow, restricted, closed, private, self-seeking, public-ignoring state. 

The first attempt at constituting a ‘governo largo’ in England was made during the Civil Wars, with the ‘Agreement of the People’. This went through several drafts between 1647 and 1649. The title was well chosen. Real, working, constitutions are produced through a process of discussion and negotiation – ‘arguing and bargaining’ – that enables a broadly acceptable constitutional settlement to be reached. The constitution expresses what been agreed, amongst the people or their representatives, as the common foundation of the state.  

Reaching such an agreement today, in a society that has become as polarised and divided as ours, will not be easy. It is nevertheless necessary. In order to establish a state that serves the common good, we must have some agreed foundations, ground-rules, shared principles, upon which a general consensus exists. This alone can provide the basis for an inclusive, publicly-oriented, ‘governo largo’.  

This is not a radical innovation. Almost every country which has become independent from the British Empire has adopted a democratic constitution as its supreme and fundamental law. In some cases – in India in 1950, South Africa in 1996, and Kenya in 2010 – a serious attempt was made to establish an inclusive ‘governo largo’ constitution. In so doing, they sought to heal deep divisions, to reach a broadly acceptable settlement, and thereby to make good government – and with it socio-economic development – at least possible. 

Perhaps we think we are better than all that, beyond such constitutional trifles. Yet, the fact remains that our politics today – and our society today – look much more like those of India, South Africa and Kenya than, say, like those of 1950s England. Either we find ways to dwell together in unity, or we face the kind of civil breakdown which the ancients referred to as ‘stasis’, in which all notions of the common good and the public interest are abandoned in partisan, factional, sectarian or ethnic conflict.  

Here then, we must return to matters of the spirit. A good constitution is necessary, but the best constitution cannot save us. A constitution might call us to liberty – to that political freedom which enables us, as responsible citizens, to exercise care for common things, through systems of representative and responsible ‘public government’, but that is not enough, unless we also cultivate the qualities of character to use liberty well and wisely.  

Saint Paul enjoins us not to use liberty ‘for an occasion to the flesh’ – that is, to seek our own, selfish, corrupt or partisan ends. He warns us perils of stasis: ‘But if ye bite and devour one another, take heed that ye be not consumed one of another.’  He also points to that one solution by which the degeneracy of the state, and the corruption of the constitution, might ultimately be overcome: ‘all the law is fulfilled in one word, even in this; Thou shalt love thy neighbour as thyself.’ 

In other words, if we wish to seek the common good, to be well governed, to live in peace and unity, with freedom and justice, then we have to learn to love one another. Civic and political regeneration cannot ultimately be separated from regeneration of our souls.  

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