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How it’s done in Switzerland

The World Conference in Brussels provided the opportunity to listen to numerous presentations from experts in the field. None of us, however, could hear every presentation. I would do a disservice to our presenters, therefore, if I attempted to summarize the work of each presenter in just a few words.
Further, many presenters provided us with written statements that were far more in depth than their spoken presentations. One of these was Klaus Hotz JD, who discussed the assessment procedures and the overall legal situation in Switzerland. What follows is an in-depth summary of his presentation with additions I have edited from his writings.

The legal situation in Switzerland

In Belgium and the Netherlands only physicians are allowed to assist people to die. In Switzerland, however, assistance is provided by non-physicians who work within the guidelines of Swiss law. These non-physicians include right to die societies such as EXIT (Deutsche Schweiz), Vereinigung für humanes Sterben. In Switzerland EXIT Deutsche Schweiz helps people die without any special law, jurisdiction or government regulations on the topic. The actions of EXIT are tolerated by the government, but watched carefully.

The Swiss Penal Code enacted in 1942 provides punish- ment (of up to five years imprisonment)for a person helping another commit suicide if that person is acting for selfish reasons. Otherwise it is not a crime.

Although this is liberal, Switzerland does not allow medical decisions to shorten life (UDSL)or euthanasia, as in the case of Holland and Belgium. On the contrary, the Swiss Penal Code forbids ending another’s life even if this person urgently wishes to die and even if helping would be reasonable.

Efforts to change the law have taken various forms, beginning in 1975 when Prof.Hämmerli, a famous professor and director of a large clinic, declared openly that he had made non-treatment decisions in 27 cases. Penal procedures, although started against him, were without consequence.

In 1977 an initiative was launched which would have allowed life terminating acts for terminally ill persons requesting it. This initiative, which asked for a change of a federal law, was accepted by 58.4%of the voters of the Canton of Zurich. Of course, such an action could not be decided on the cantonal level and the Federal Parliament refused to take action.

In 1994 a new initiative was launched in the Federal Parliament, the so-called “Motion Ruffy.” It was dealt with slowly. A special commission began work in 1997 and issued a detailed report in 1999. It proposed several changes of the law that would have allowed various forms of aid-in-dying, ranging from allowing non-treatment decisions (NTD), to allowing alleviation of pain and symptoms with opiates in doses with a potential life-shortening effect (APS),to a proposal for life- terminating acts. The Federal Parliament has left the matter open for the future.

In the mean-time, different cantons of Switzerland have enacted laws protecting patients, confirming the choice of individuals to decide about treatments to be made or not. These “advance directives” containing instructions to stop unnecessary treatments have become generally accepted.

The medical community in Switzerland

Similarly important in this debate are the restrictive rules of the Swiss Academy of Medical Science. Since 1976 there has been a specific rule regulating aid-in-dying, which this has been changed several times. The latest version, rewritten in 1995,allows only non-treatment decisions (NTD),and also contains a statement that “assisted suicide is a non-medical activity.” Legislatures (and opponents)have had a tendency to refer to this regulation.

Nevertheless, there are many doctors who are unwilling to follow the recommendations. For example, a 2001 survey of members of the Swiss Society for Palliative Medicine found that:

  • 44% of members support physician-assisted suicide (PAS);
  • 32% are in favor of liberalizing life-terminating acts;
  • 10% acknowledge having performed physician-assisted suicide or aid in dying; and
  • 63% have experience with the alleviation of pain in ways that had a potential life-shortening effect (APS)

The Swiss practice of assisted suicide

Hotz then described the activities of the three different Swiss right to die societies, two of which are members of the World Federation:

EXIT (Deutsche Schweiz) Vereinigung für humanes Sterben, the oldest Swiss right to die society with more than 50,000 members, performed 124 assisted suicides in 2001 (96 in 2000). In addition, it opened 240 files without an assisted suicide and provided consultation about assisted suicide to around 1,000 persons.

The second oldest society, EXIT A.D.M.D. (Suisse Romande), with around 10,000 members, performed some 40 assisted suicides in 2001 (20 in 2000).

The newest organization, DIGNITAS, which is not a World Federation member society, apparently has some 1,700 members, of which about 1,000 are foreigners. Dignitas performed around 50 cases in 2001.

All three societies are using a combination of barbiturates and an anti-cholinergic drug called “Natrium-Pentobarbital” (NaP). The patient falls deeply asleep within 10 minutes. Death then normally comes within 15 to 60 minutes. The NaP can also be given in an infusion, but the person willing to die must be able to open the lever. This procedure is seldom used, but is available for individuals who are unable to swallow the medication. When a person cannot initiate his own death EXIT is unable to help because laws only allow for assistance in suicide, not euthanasia. In EXIT'[s experience, no procedure ever had to be interrupted or was otherwise unsuccessful.

Public Opinion

Assisted suicide is a continuous subject of discussion in Switzerland, and public acceptance is large and still growing. Its opponents are primarily religious conservatives even while the protestant church in Switzerland has become more and more accepting of the practice. There also has been some opposition by members of the medical profession, and EXIT is often discredited with untrue arguments by sensationalists in the press alleging scandals and so-called “angels of death” who supposedly induce people to commit suicide.

To assess public opinion EXIT commissioned a survey in October 2000.Results confirmed a prior survey by EXIT Suisse Romande in the French speaking portion of Switzerland, and showed that:

  • 90% agreed that a terminally ill person should have the possibility for passive aid in dying (non-treatment decision).
  • Some two-thirds would like to receive strong medication to shorten their lives when they are terminally ill (APS).
  • 84% think that a doctor should be allowed to give strong medication to shorten life when the patient is asking for it.
  • 50% are of the opinion that after thorough investigations and in addition to doctors, organizations like EXIT should have the right to give the necessary medication to die.

Additional evidence of public support can be seen in actions taken in October 2000 by the City Council of Zurich, which decided to abolish a regulation that had prohibited right to die societies such as EXIT from entering and pursuing their activities in nursing homes and home for the elderly owned by the city. This decision was made after receiving positive opinions from experts in the fields of law, theology/ social-ethics, and ethics.

This decision created a heated discussion in the press for several months, but has now been accepted because the feared worst-case scenarios have not come to pass. There has been no abnormal increase of suicides and, EXIT has not coerced anyone into suicide.

Assisted suicide by EXIT

Since its foundation EXIT has become the largest society for the right to die in Switzerland. It has the means to act on a professional level, which has become important due to its high profile and the close scrutiny it receives.

Organization. EXIT ‘s main body is a board elected by the general assembly. One of the board members is head of the team responsible for assisted suicide. The selection of this team, which numbers around 20, requires close supervision. Working on this team is very demanding, but team members receive no financial remuneration. Team members have to fulfill the necessary prerequisites to carry out this demanding work, and attend regular meetings and training needed to meet the quality standards.

To further avoid problems EXIT has created two separate commissions. The ethics commission deals with difficult cases, and the compliance commission checks on all activities.

Requirements for assistance. Based on current law EXIT requires the following two conditions to assist in a Death. These include:

  1. Poor medical prognosis, unbearable pain or unsustainable impairment; and
  2. Full discretion (mental competency)of the person committing suicide.

EXIT has primarily helped individuals with cancer, Parkinson’s, MS (Multiple Sclerosis), or ALS (Amyotroph Lateral Sclerosis) with suffocation attacks. Cancer patients comprise the largest group. Particularly urgent are cases in which a patient is suffocating. Additionally urgent are extremely painful cancer cases.