Under what conditions is euthanasia permitted?

Switzerland is known for its liberal regulations on assisted suicide. What should be permissible in this ethically sensitive area requires careful consideration. Below you will find a compilation of the framework conditions and actors on the topic of euthanasia.

Social and constitutional embedding of euthanasia

People naturally think about dying and death. Some people, especially those with incurable diseases that cause severe suffering, may feel a wish to die. The wish to end one’s own life often has a complex background. Thus, this depends not only on the disease itself and the associated reduced quality of life. One’s own biography, needs as well as attitudes and concerns of those affected, but also of the social environment, can also have an effect on the wish to die.

The starting point and fundamental justification of assisted suicide and euthanasia is the right to personal freedom and self-determination. This is guaranteed in the Swiss Federal Constitution and the jurisdiction concerning the European Convention on Human Rights. In addition to the right to determine one’s own life, it also includes the right to end it voluntarily. No one can be forced to continue living against their free will.

In order to ensure a dignified end of life, patients sometimes decide to use the services of euthanasia organisations. In addition to counselling and support for persons willing to die and their relatives, these also offer a framework for so-called ‘medically assisted suicide’. This involves dispensing a medically prescribed euthanasia drug (usually sodium pentobarbital) to be taken by the person wishing to die. Compared to other suicide acts, this procedure is characterised by its high level of safety, painlessness and strict control measures.

Legal framework for euthanasia

What are the requirements for assisted suicide in Switzerland? First of all, a distinction needs to be made between euthanasia and assisted suicide. These two acts are in fact different offences under the Swiss Criminal Code(StGB). Assisted suicide and passive euthanasia(by refraining from life-prolonging treatments) are further groups of cases, which are dealt with in more detail in elsewhere.

Active euthanasia, on the other hand, means ending a person’s life at their request, or providing them with substantial assistance in doing so. So-called participation plays an important role in this. The execution of the act(s) leading to death lies with the person who performs euthanasia – and not with the person who wants to end his or her life. Such an act is prohibited and punishable under Art. 114 Swiss Criminal Code:

Any person who, out of respectable motives, namely out of compassion, kills a person at that person’s earnest and insistent request shall be liable to a custodial sentence not exceeding three years or to a monetary penalty.

Art. 114 Killing on demand

Therefore, it is also not possible to demand the provision of active euthanasia. The situation is different in the case of assisted suicide or suicide assistance. In this case, the person who wants to end his or her life has the power of action. In order to be able to take a means of dying, a doctor’s prescription is required. It is therefore mandatory for doctors to participate in medically assisted suicide by issuing a prescription for the drug. However, they have no influence on the intake by patients. It is of paramount importance to have a clean and comprehensive documentation of all processes related to medically assisted suicide. In this way, conflicts of interest and subsequent ambiguities can be avoided. In addition, professionals thus protect themselves from criminal and medical ethical liability, since inducing or assisting suicide for selfish motives is also punishable under Art. 115 Swiss Criminal Code:

Any person who, for selfish motives, induces or assists someone to commit suicide shall, if the suicide has been carried out or attempted, be liable to a custodial sentence not exceeding five years or to a monetary penalty.

Art. 115 Inducement and aiding and abetting suicide

On the other hand, assisted suicide is unpunishable, provided it is done without ‘selfish motives’. This applies to all persons, including healthcare professionals. This shows the area of tension in which doctors move when participating in assisted suicide.

Medical-ethical guidelines: dealing with dying and death

In practice, the Guidelines of the Swiss Academy of Medical Sciences (SAMS)are consulted in order to provide guidance to medical practitioners beyond these legal provisions. These distinguish between generally accepted, controversial and prohibited acts. Passive euthanasia(‘omission and termination of life-sustaining measures’) and palliative medical treatments that can result in a shortening of life (‘relief of pain and other symptoms as well as sedation’) are considered generally accepted. Such procedures are permissible if they are required by symptoms of the disease and have the patient’s consent. These acts may be required in particular if the person concerned has expressly and bindingly requested them in a valid Patient Decree. The accompaniment of so-called ‘death fasting’ and assisted suicide, which will be examined in more detail below, are controversially discussed. In accordance with the legal framework, the killing of a human being in any case, whether with or without the person’s request, is also strictly forbidden to doctors.

The SAMS guidelines also define the conditions under which medical professionals may provide assisted suicide. First of all, they state that every medical professional must make the decision for themselves as to whether they can reconcile the support of suicide acts with professional ethics and their good conscience. It is therefore up to each doctor to refuse to prescribe euthanasia drugs, and they cannot be forced to do so:

«The role of the doctor in dealing with dying and death is to relieve symptoms and accompany the patient. It is neither part of his duties to offer assisted suicide of his own accord, nor is he obliged to do so. Assisted suicide is not a medical act to which patients could make a claim, but it is a legally permissible activity»

SAMS Guidelines: dealing with dying and death

Conversely, medical professionals are required not to influence patients through their values. Rather, they should advise them constructively and solution-oriented about possible alternatives. If, after careful information and clarification, a health professional is in principle prepared to prescribe a means of dying at the self-determined request of the person willing to die, he or she must check five basic requirements:

  1. Die Patientin bzw. der Patient muss in Bezug auf den assistierten Suizid urteilsfähig sein. Falls ein Zustand vorliegt, der häufig mit fehlender Urteilsfähigkeit verbunden ist (bspw. eine Demenzerkrankung), ist dieser durch einen Facharzt zu evaluieren. Da es sich beim Freitod um eine besonders folgenschwere Entscheidung handelt, ist an die Urteilsfähigkeit sowie deren Dokumentation ein höherer Massstab anzulegen als bei einfachen, alltäglichen Belangen.
  2. Der Sterbewunsch muss wohlerwogen und dauerhaft sein. Er darf nicht auf äusseren Druck entstanden sein, sondern muss dem frei gebildeten Willen der Patientin bzw. des Patienten entsprechen. Falls Hinweise auf ein Abhängigkeitsverhältnis bestehen, ist dessen möglicher Einfluss auf den Suizidwunsch sorgfältig zu untersuchen, um Fremdeinwirkung auszuschliessen.
  3. Krankheitssymptome oder Funktionseinschränkungen von Patientinnen oder Patienten sind für diese Ursache unerträglichen Leidens. Damit die Suizidhilfe in den medizinischen Zuständigkeitsbereich fällt, müssen medizinisch fassbare Krankheitssymptome oder Funktionseinschränkungen vorliegen. Der assistierte Suizid soll nicht auf gesunde Personen ausgedehnt werden. Dabei ist jedoch zu berücksichtigen, dass «unerträgliches Leiden» von der subjektiven Sicht der betroffenen Person ausgeht und nur schwer objektivierbar ist. So können etwa auch schwere Depressionen einer körperlich gesunden Person unerträgliches Leiden verursachen. Daher ist bei der Beurteilung dieses Kriteriums besonderes Einfühlungsvermögen und die Bemühung um ein vertieftes Verständnis der individuellen Lebenslage unbedingt erforderlich.
  4. Therapien sowie andere Hilfs- und Unterstützungsangebote wurden gesucht und sind erfolglos geblieben oder werden von der sterbewilligen Person als unzumutbar abgelehnt. Die Patientin bzw. der Patient muss sämtliche Alternativen zum assistierten Suizid versucht oder zumindest gründlich erwogen haben und dennoch dauerhaft auf dem Sterbewunsch beharren.
  5. Der Patientenwunsch, in einer Leidenssituation nicht mehr weiterleben zu wollen, ist für den Arzt aufgrund der Krankheitsgeschichte und wiederholter Beratungen nachvollziehbar, und es ist für ihn vertretbar, im Einzelfall Suizidhilfe zu leisten. Die Ärztin bzw. der Arzt muss jeden Fall, in welchem sie oder er ein Sterbemittel verschreibt, einzeln und gesamthaft auf Basis aller vorhandenen Informationen prüfen. Nur aufgrund einer sorgfältigen Bewertung und Abwägung sämtlicher Fakten im Einklang mit den obigen Grundsätzen darf sie oder er das Rezept für ein Sterbepräparat ausstellen.

A third person must additionally confirm the fulfilment of the first two requirements. The prescription of a drug for the purpose of suicide must be reported to the competent cantonal authorities within 30 days. Since an assisted suicide is an ‘extraordinary death’ within the meaning of the Swiss Code of Criminal Procedure(StPO), a forensic medical examination (legal inspection) is indicated in every such case.

Who is involved? Who can I contact?

Earlier in the text, a large number of actors were mentioned who are involved in a complex interrelationship and division of tasks around medically assisted suicide.

The preparation of such a death always starts with the person who wants to die. The latter must form its will independently, well-balanced and free from external influence.

However, due to the implications of such a decision, relatives, i.e. in particular family members and other close persons, must also be involved in the process. According to the SAMS guidelines, ‘the patient should also be motivated to talk to relatives about his or her desire to commit suicide’. This is the only way to reliably ensure a dignified farewell, but also estate planning and the implementation of last wishes.

The role of doctors as gatekeepers, as key persons for the dispensing of prescription drugs, has already been described. Likewise, the legal and medical ethical framework within which they make their decisions about assisted suicide participation was addressed.

In probably almost all cases, euthanasia organisations are also involved in assisted suicide. The best-known organisations in Switzerland are EXIT and Dignitas. These are two non-profit associations. Their purpose is to enable their members and other persons to live and die in dignity. To this end, they offer counselling on end-of-life issues, patients’ rights and suicide prevention in close cooperation with medical professionals, clinics and hospitals. In addition, they prominently advocate liberal positions on assisted suicide in legal policy discourse.

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Summary of the most important points

  • Die im europa- und weltweiten Vergleich liberale Rechtslage in der Schweiz ermöglicht in einem gesetzlich und medizinethisch festgelegten Rahmen die Suizidhilfe. Ärztinnen und Ärzte können eigenverantwortlich darüber entscheiden, ob sie daran mitwirken. Patientinnen und Patienten haben keinen Rechtsanspruch darauf.
  • Damit der assistierte Suizid zulässig ist, muss die sterbewillige Person die Handlung, die zum Tod führt, selbst vornehmen. In aller Regel handelt es sich dabei um die Einnahme eines ärztlich verschriebenen Sterbemittels infolge eines standardisierten Vorbereitungsprozesses. Zumeist wird dieser von gemeinnützigen Organisationen wie EXIT oder Dignitas durchgeführt, die sich auf das Thema spezialisiert haben.
  • Bei der Vorbereitung eines assistierten Suizids treffen die beteiligten Fachpersonen diverse Sorgfalts- und Dokumentationspflichten. So müssen sie namentlich abklären, ob die sterbewillige Person urteilsfähig ist. Zudem müssen sie feststellen, ob ihr Sterbewunsch angesichts der Lebenssituation sowie der Therapiealternativen wohlerwogen, dauerhaft und nachvollziehbar ist.
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