Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2013 Nonphysician-assisted suicide in Switzerland Andorno, Roberto DOI: https://doi.org/10.1017/S0963180113000054 Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-92579 Journal Article Originally published at: Andorno, Roberto (2013). Nonphysician-assisted suicide in Switzerland. Cambridge Quarterly of Health- care Ethics, 22(3):246-253. DOI: https://doi.org/10.1017/S0963180113000054 Cambridge Quarterly of Healthcare Ethics, 2013, vol. 22, n° 3, p. 246-253 Nonphysician-Assisted Suicide in Sw itzerland ROBERTO ANDORNO 1) Nonphysician assisted suicide is An Unintended Permissive Policy permitted. Whereas in the on Assisted Suicide Netherlands and Belgium only physicians are allowed to assist in In general, legal responses to end-of-life a suicide, in Switzerland this issues are not very different in assistance is provided by (non- Switzerland than in most European physicians) volunteers working countries. For instance, active for nonprofit organizations. The euthanasia (i.e. killing on request) is role of doctors is limited to illegal, although it is treated as a lesser prescribing the lethal drug and offense than murder or manslaughter. assessing the patient’s decisional Article 114 of the Swiss Penal Code reads, capacity; they do not perform the “Every person who, for honorable reasons, assistance in the suicide especially mercy, kills another person on themselves.2 In this regard, the his or her serious and pressing request practice of assisted suicide in shall be punished by imprisonment for a Switzerland is similar to the one maximal term of three years or with a in the US state Oregon.3 fine.” Also, like in most European 2) One need not have a particular countries, the administration of medical condition (such as a medication (for instance, morphine) to terminal illness or an unbearable relieve serious pain of a terminal patient, suffering) to request assistance even though it may lead to the with suicide. The only unintended consequence of hastening requirement is that the individual his or her death, is accepted, in both must have decisional capacity, moral and legal terms. Similarly, like in because in the absence of it his or many other countries, the withdrawal or her act cannot be considered a withholding of life-sustaining “suicide” in legal terms. In fact, at treatments, even if not covered by any present, according to a recent specific legal provision, is not treated as study, around 25% of people who a criminal offense provided that certain die by assisted suicide in conditions are fulfilled.1 Switzerland do not have any The peculiarity of Switzerland serious or terminal illness, but regarding end-of-life issues only relates are just old, or are simply “tired to assisted suicide. This practice, which of life”.4 is permitted, has two significant differences if compared to the situation The peculiarity of the Swiss situation is in the other (few) European countries due to the circumstance that, unlike that allow it: other countries allowing assisted suicide, Switzerland does not have any specific legal norms regulating this practice. This assisted suicide explains the two current situation has developed, not as aforementioned gaps in the Penal Code the result of an explicit liberal policy, but when compared with the provisions of rather at the initiative of non- other countries allowing this practice. governmental right-to-die organizations, First, it does not make any mention of which took advantage of a gap in the physicians in the practice of assisted legal system. The draft Penal Code, suicide. Second, no particular medical which was submitted to the Parliament condition is required to request in 1918 and approved in 1937, already assistance with suicide. included the current Article 115, entitled Therefore, in Switzerland, anyone “inducement and assistance to commit can in principle assist an individual to suicide”, which reads: “Every person who, commit suicide, and any competent for selfish reasons, incites or assists person can request such assistance. someone to commit suicide, shall be However, as mentioned previously, sentenced to imprisonment of up to five assisted suicide is in fact performed by years or a fine.” volunteers working for nongovernmental This article is interpreted a contrario organizations, and not by physicians. as meaning that assistance with suicide Interestingly, according to a study is not a criminal offense when it is conducted in 2009, 80.4 % of Swiss practiced without any self-interested doctors are reluctant to be directly motivation. There would be a selfish involved in this practice, which they motivation if, for instance, the assisting consider to be a “nonmedical person would inherit the one who is intervention” (although the majority of seeking to die, or would benefit in some them do not regard the practice itself as other way from the death of the latter. morally reprehensible).6 But because nonprofit organizations do In addition, the Swiss Academy of not have, in principle, any selfish Medical Sciences issued in 2004 motivations for helping someone to guidelines on this matter expressing commit suicide, their activities are not serious reservations about the illegal. involvement of physicians in assisted Certainly, Article 115 of the Penal suicide. Paragraph 4.1 of the guidelines Code was not originally conceived with specifies that “the proper task of doctors the purpose of “legalizing” assisted is to relieve patients’ suffering, not to suicide, let alone facilitating the offer them assistance to commit activities of nongovernmental suicide.”7 The rationale of this statement organizations involved in this practice. is that doctors’ involvement in their Rather, the authors of the draft Penal patients’ suicide risks creating confusion Code had in mind the situation of about the proper aim of the medical somebody who assists a desperate profession, on the side not only of the individual wanting to end his or her life patients, but also of doctors themselves. for some personal reasons; the It should be noted that these guidelines lawmakers decided to exclude have been incorporated into the imprisonment when the assisting Professional Code of the Swiss Medical individual acted without any personal Association (Federatio Medicorum interest. The whole parliamentary Helveticorum, FMH) and, in this way, discussion in the 1930s did not envisage they are binding for all practitioners. at all suicide assistance from a medical However, the Academy itself nuanced perspective. It was, rather, inspired by the statement made in Paragraph 4.1. “romantic stories about people while acknowledging, in the same committing suicide in defence of their paragraph, that if a doctor, in accordance own, or their family’s honour, and about with his conscience, decides to assist in a suicides committed by rejected lovers”.5 suicide, his decision has to be respected: The unintentional character of the current permissive regime regarding “On the one hand assisted suicide is not be disabled in a serious manner.” Exit part of a doctor’s task, because this workers follow a protocol and use a contradicts the aims of medicine. On the checklist to document what was other hand, consideration of the patient’s wishes is fundamental for the doctor- discussed at the initial visit and all patient relationship. This dilemma subsequent contacts. Most members who requires a personal decision of conscience are considered eligible for assistance are on the part of the doctor. The decision to close to death, and Exit routinely provide assistance in suicide must be recommends both hospice care and respected as such. notification to the family. The In any case, the doctor has the right to association has two branches: Exit refuse help in committing suicide. If he decides to assist a person to commit Deutsche Schweiz, which operates in the suicide, it is his responsibility to check the German-speaking part of Switzerland, following preconditions: the patient’s with headquarters in Zurich, and Exit disease justifies the assumption that he is ADMD (Association pour le Droit de approaching the end of life; alternative Mourir dans la Dignité) for the French- possibilities for providing assistance have speaking part of the country, with been discussed and, if desired, have been headquarters in Geneva. They have implemented; the patient is capable of making the decision, his wish has been well 55,000 and 10,000 members thought out, without external pressure, respectively.8 and he persists in this wish. This has been Dignitas was created in 1998 by the checked by a third person, who is not lawyer Ludwig Minelli and offers necessarily a doctor. The final action in the assisted suicide to nonresidents in process leading to death must always be Switzerland. It has at present 5.500 taken by the patient himself.” members.9 People seeking to end their lives have to register with the society, The Role of Nongovernmental pay a registration fee (200 Swiss Francs: Organizations in Assisted Suicide around 160 Euros), and an annual fee of 80 Swiss Francs, and when (and if) they The debate on assisted suicide in decide to kill themselves, they have to Switzerland has essentially to do with pay a total amount of 6,000 Francs the role of nonprofit organizations (around 5,000 Euros), which includes offering that assistance, and not with the the administrative and burial costs. involvement of physicians or with Members also have to give a power of particular medical conditions for such a attorney to the society for all the request. There are two main non- administrative procedures. Most people governmental organizations involved in seeking assistance to suicide come from this practice: Exit and Dignitas. They Germany, the UK, and France. More usually perform the suicides in their own than 100 Britons have been assisted to accommodations.