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

Culture

Freedom

Justice

11 September 2025

4 min read

Free speech for me, but not for thee

A hate crime hoo-ha and the limits of free speech

George Pitcher

George is a visiting fellow at the London School of Economics and an Anglican priest.

Two brown bears fight while baring their teeth.

Zdeněk Macháček on Unsplash.

It was the the legendary Manchester Guardian editor CP Scott who said “Comment is free, but facts are sacred.” His dictum hay have held a century ago, but it doesn’t stand up today. In post-truth societies, facts are anything but sacred. And, leaving aside for now whether the opposite of sacred is freedom, comment isn’t free either.

I don’t mean in the sense of whether or not you have to pay for it – you’re not paying for this, for example – but whether comment, as Scott took it for granted to be, is an act of freedom. Graham Linehan, the Father Ted comedy writer, temporarily lost his freedom to a squad of police officers at Heathrow airport for a social media post he’d tweeted: "If a trans-identified male is in a female-only space, he is committing a violent, abusive act. Make a scene, call the cops and if all else fails, punch him in the balls."

The subsequent hoo-ha has precisely been about whether Linehan should have been free to make his comment. The police, under prevailing hate-crime laws, felt obliged to arrest him. Subsequently the media, politicians and assembled chatterati – even the Met Police commissioner weighed in – wailed how ridiculous it all was and, adopting serious-face, what a threat it represented to free speech, which is one of the most potent graven images of our time. Facts may be free these days, but comment is sacred.

Except it also depends whose comments and opinions are deemed sacred. So some people’s speech is more free than others. Take the Free Speech Union (FSU), founded by the liberally-challenged Toby Young. Here, right-wing freedom of speech is inalienable and non-negotiable. So silly intrusions into the views of Islamophobes and critics of trans-activism? Outrageous. But supporters of Palestine Action (PA), nearly 1,000 of whose supporters had to be arrested by police for peacefully holding placards? Not a word. They’re all lefties, you see.

As Hugo Rifkind pointed out in The Times, neo-conservative and FSU director Douglas Murray was asked by Daniel Finkelstein whether his free-speech principles extended to PA’s superannuated supporters. Apparently not. And Reform UK’s Richard Tice simultaneously believes that protesters outside asylum hotels are “part of who we are”, but that the correct response to PA protesters is to “arrest and charge the lot. Jail them.” Forgive me, but I thought a central tenet of faith in free speech is that it’s consistently applied?

“Part of who we are ” used to be a tolerant, inclusive and pluralistic society. Not just campaign for our lot and bang up all the rest. And I’d contend that we should self-regulate freedom of speech rather than legislate for it. The Met Police commissioner, Sir Mark Rowley, seems to agree with that: “Regulations that were understandably intended to improve policing and laws that were intended to protect the vulnerable are now tying officers’ hands, removing appropriate professional discretion — which some call common sense.”

That “common sense” is much beloved of freedom-of-speech warriors at places such as FSU. But they always get to define what it is and who gets to benefit from it, because it’s tribal. “If they pick on you, we’ll pick on them,” declares Young on his FSU website. It’s freedom for my tribe to say what it likes, not yours. And freedom of speech is meaningless if it’s not for everyone, including your political enemies.

Where we agree is that freedom of speech should not be adjudicated by the law. There are enough laws without legalising what people can’t say or write. Where, I imagine, we disagree is that it shouldn’t be adjudicated by Young and Murray and Tice either. As matters stand, we have those who want to legislate for the right to free speech and those who campaign to restrict it. Nothing can come of that.

By regulating ourselves, the risk is run of sounding conservatively nostalgic for a golden age of civility that never really existed, or rather that was imposed by social authority. It’s the sort of proposed solution you hear when someone says it’s really a question of good manners. It’s true that freedom of speech largely worked in a period of deference, but deference was probably not a good price to pay for it.

What can be said is that, like any freedom, freedom of speech comes with congruent responsibilities. We hold a responsibility not to cause violence with what we say, even or especially if that means turning the other cheek. In ecclesiological management terms, this would make freedom of speech a pastoral rather than systemic provision. We serve each other; we don’t require the state to serve us.

Linehan’s post was fine up until it’s final phrase. But it’s peer pressure, not the law, that should have prevented him from using it. Taking the violence out of speech should be an educated, peaceful instinct. And that remains a social duty, not a governance one.

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