Suicide assistance in Switzerland: for palliative care physicians, the reality is more complex than you might think

By Martyna Tomczyk.

As is well known, assistance in suicide is allowed in Switzerland. Although this practice is not explicitly regulated by law, Article 115 of the Criminal Code stipulates that assisting someone to commit suicide is only punishable if this is carried out for selfish reasons. Private right-to-die organizations have developed their activity in the country by referring to this article.

The role of physicians in suicide assistance is usually limited to assessing the individual’s decisional capacity and prescribing a lethal dose of natrium-pentobarbital. Anyone can assist in a suicide – including laypersons – and, in those circumstances, a doctor would act as a ‘private citizen’, not as a ‘physician’. For this reason, the practice cannot be labelled ‘physician-assisted suicide’, the term by which it is generally known in other countries.

As is also commonly known, assistance in suicide is contrary to the philosophy of palliative care, and should not be included in its practice. In this context, a question that can be raised is how assistance in suicide can coexist with palliative care in Switzerland, given that these two practices seem to pursue opposite goals.

Empirical studies show that Swiss palliative care physicians regularly receive assisted suicide requests from their patients. The Swiss Academy of Medical Sciences has developed guidelines to help physicians, but these are rather general and it is not known which concrete steps to take and which not. Studies indicate that, lacking clear guidance on this issue, Swiss palliative care physicians manage each patient’s request in line with their own professional and personal values, but would prefer well-defined legal regulation.

Together with Ralf Jox and Roberto Andorno, I conducted an empirical study to explore the attitudes and experiences of palliative care physicians with regard to the current legal situation on assistance in suicide in Switzerland. Our study, based on face-to-face interviews with physicians in various palliative care centres in the French-speaking part of Switzerland, shows that the reality of the work of palliative care physicians is more complex than one might think. All the participants stated that assisted suicide, as offered by Swiss right-to-die organizations, and palliative care are generally opposing approaches. However, most of them pointed out that they were currently observing a paradigm shift in Switzerland.

In the past, the two approaches were in such strong opposition that one of our participants even referred to the situation as something of ‘a religious war’; ‘We insulted each other, from a distance, even face to face’. Now, although right-to-die organizations continue to pursue a philosophy contrary to that of palliative care, some of the study participants considered it a complementary approach that can have a positive impact on the patient-physician relationship. As our results indicate, the reasons for this paradigm shift probably lie in both palliative care and right-to-die associations opening up to each other in a context of increasing societal acceptance and normalization of assisted suicide in Switzerland, as well as in Western Europe in general.

Our study confirms that palliative care physicians were unsure about their role in the event of a patient’s request for suicide assistance. Although they conduct some activities that may count as assistance in suicide (e.g., establishing medical certificates confirming the eligibility criteria), they are reluctant to engage in others (e.g., contacting EXIT). Two of the participants in our study mentioned physicians who work in palliative care and who also volunteer for a right-to-die organization, and considered this double role inappropriate. This aspect should be explored more deeply. In particular, it would be interesting to interview Swiss palliative care physicians who also volunteer for right-to-die societies and to explore and describe their normative and practical framework, as well as the personal and moral values that led them to take that path.

Interestingly, the lack of a clearly defined legal framework for responding to a patient’s request for assistance in suicide does not generally seem to be a problem for the physicians in our study. On the contrary, most of them explicitly stated that the legal liberty suits them and that they have no desire to change the situation in any fundamental way.

However, all the participants felt that the activities of right-to-die organizations needed to be regulated. One of the reasons for this, although only mentioned by one participant, seems particularly important. Assistance in suicide is not free of charge in Switzerland and the financial aspects of access to suicide assistance by private right-to-die organizations are considered to lack transparency and ethical justification. As already mentioned, article 115 of the Swiss Criminal Code explicitly states that assisting suicide is a crime if (and only if) it is driven by selfish motivations. The absence of financial transparency in the private organizations would put into doubt the non-selfish nature of their assistance in suicide and, consequently, the legality of this practice.

 

Paper: ‘How is it possible that at times we can be physicians and at times assistants in suicide?’ Attitudes and experiences of palliative care physicians in respect of the current legal situation of suicide assistance in Switzerland

Author: Martyna Tomczyk

Affiliations: Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne.

Competing interests: None declared.

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