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.

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1 September 2025

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Is your child school ready?

What really matters as a child develops

Henna Cundill

Henna is a researcher with the Centre for Autism and Theology at the University of Aberdeen.

A teacher looks on as a young child concentrates on writing.

Department for Education.

In the coming weeks, those little critters will start to emerge, easily identified by their autumn plumage of coloured sweatshirts and oversized backpacks. Anxious parents and caregivers can be spotted, shepherding their young along paths and pavements, casting worried glances left and right at the pelican crossings. Listen carefully and you may hear the squeak of uncomfortable new shoes and juveniles complaining about the wearing of a coat, as adults of the species re-establish social bonds with cries of, “Back to school already, I can’t believe how fast it’s gone!”

As they congregate upon the tarmac staging ground, some will be taking part in this ritual for the very first time. Neophytes who have maintained social bonds throughout the pre-school years might be seen to greet their fellows cordially, “Did you have a good summer? Can Flo make it to Izzy’s party?” Others will stand alone, scanning the playground for a half-remembered face from the bygone days of antenatal classes. That was only five years ago, but it feels like a millennium. The faces are changed; everyone looks more…tired.

The world has been turned upside down in those past five years. It’s been said so often that it is almost trite, but nonetheless true: nothing prepares you for becoming a parent. In the UK, new parents increasingly raise their children without the immediate support of extended family, coupled with the tyrannous expectation that one will retain one’s employment rank and contribution to the labour market alongside this new and 24/7 full time job of looking after baby. The Key Performance Indicators of parenting are ambitious. Deliverables for the first five years include toilet training, instilling speech and language skills, establishing basic recognition of 26 alphabetical characters (including the child’s ability to recognise the alphabetical sequence that spells their own name) and ensuring the recognition of and (ideally) ability to correctly sequence numbers 1 to 20. If your child can do all of this by the age of 5, whilst also learning not to punch, kick or bite other children, not to eat food off the ground, and not to stick rocks up their nose, then congratulations! Your child is school ready!

It may comfort some readers to know that very few 5-year-olds manage to hit absolutely all of these milestones. As the education secretary, Bridget Phillipson, commented recently – parenting is too hard. She is working to establish a new iteration of Labour’s ‘Sure Start’ programme (rebranded as ‘Family Hubs’) to offer parents more support in the community. As part of her rationale she states, “When one in four children are leaving primary school without having reached a good level of reading, then something’s gone seriously wrong in those early years that has to go beyond the school gate.”

Whilst I’m keen to see more support for new families – I’m intrigued by this particular rationale for it. Ability to read well by a certain age seems an unlikely metric by which to measure whether a child has had a positive experience of childhood; it appears indicative of what autism-researcher Anne McGuire calls “The normative time of childhood,” in which the success is measured against an imagined future of economically productive years. By this metric, if a child learns to read at a prodigiously young age this is taken as an indicator that they will enter the workforce with greater velocity than their peers, essentially that they will have “more future-yet-to-be-realized” than those around them. McGuire writes, “In a neoliberal regime where ‘time is money’, the child is figured as ‘time-rich’ and so represents a good investment opportunity indeed.”

McGuire’s analysis is piercingly accurate of how we often talk about our children, despite knowing all too well that it represents a fallacy. There are multitudinous stories of adults who have gone on to make staggering contributions to human flourishing, despite being placed (literally or figuratively) under the dunce’s cap at school. But even without focusing on those who go on to excel, those who attract fame, fortune, or both, we don’t have to look far to find cause to re-evaluate what it means for a child to be school ready.

My son’s year group recently finished their own primary school journey, and a quick glance through some of the leavers’ books reveals that children are very good at valuing each other for what is here in the present, without recourse to an imagined economic future. As children wrote goodbye messages for each other they said things like,

“Thank you for always having such good ideas for games to play.”

“You helped me on my first day when I got lost.”

“You’re a great house captain and you always help the teacher.”

No one was particularly keen to predict fame and fortune for the future of their friends, and there was an understandable indifference towards academic milestones. As a literary corpus, the leavers’ books were testament to the old adage that people will not remember you for what you say or do but will remember you for how you make them feel.

One the subject of childhood, Jesus once said something that defies easy explanation. He was out, teaching in the open air, surrounded by crowds of adults including important religious leaders and wealthy individuals who wanted to ask complex and deep theological questions, but in the midst of it all there were parents bringing their children, elbowing their way to the front of the crowd to ask Jesus to pray for their little ones. When some of Jesus’ followers tried to usher the children away, Jesus said, “Let the little children come to me, and do not hinder them, for the kingdom of heaven belongs to such as these.” The precise meaning of this utterance has eluded thinkers and theologians for centuries – what exactly is it about childhood that Jesus was alluding to?

I wonder if it is something about the capacity of children to live in the immediate, and therefore to value what really matters – justice, kindness and friendship. In primary school, yes it helps in some ways for children to arrive aged 5 with a certain command of the alphabet and the ability to finish the day wearing the same set of underwear that they arrived in. But perhaps what matters more is children arriving ready to enter the fray of friendships – being kind, being helpers, having the self-confidence to know that they have something to give to the learning community that they are joining, whatever their learning speed might be. Such things are gloriously untethered to economic potential or a future-yet-to-be-realized, but they are closely tethered to a child’s understanding of themselves as a valuable and important person. If Labour’s intention to offer new parents more help in the community goes some way towards communicating to our pre-school children that they have that have – and will always have – value, regardless of what they will or won’t attain to academically or economically, then it will help many more children reach the milestone of being school ready.

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