Is it a liberal right to be able to decide for yourself when to end your life? Is it the duty of doctors to assist those who choose that enough is enough? What can be done to make the final stages of life better for those who see no other way out than death? At a discussion hosted by the Friedrich Naumann Foundation for Freedom, panelists and audience grappled with these and other questions surrounding end-of-life legislation. As European countries such as the UK, France and Germany struggle to refine their position on end-of-life legislation, countries such as Switzerland and Belgium offer a wealth of experience to draw from.
EXIT – the Swiss way
Switzerland is the country in Europe with the longest experience of assisted dying legislation, with legislation dating back to 1942. As a compliment to this legislation the non-governmental organization EXIT supports its members through the creation of living wills, palliative care, counselling in case of illness or old-age issues, suicide prevention and finally physician-assisted suicides. EXIT was founded in 1982 and operates as a membership-based organization. Bernhard Sutter, Managing Director of EXIT, explained the organization’s full repertoire of services to its members and interestingly pointed out that since EXIT was founded, it has been associated with a decline in the rate of assisted dying cases in Switzerland.
By providing all these services to individuals inclined to end their lives, EXIT fulfills a key function in more often than not helping people out of a situation where death seems to be the only exit. The longevity of the assisted dying laws in Switzerland has, according to Bernhard Sutter, meant that the Swiss public has accepted the need for organizations such as EXIT. Interestingly, the threat to EXIT and the future of assisted dying in Switzerland now primarily comes from German immigrants, especially medical professionals, who are not socialized to accept assisted dying as a part of the role of medicine. Sutter was also quick to make the point that given the aging population in Europe, the need for assisted dying and organizations such as EXIT will continue to grow in the foreseeable future.
Can we have EXIT without physician-assisted suicide?
As Bernhard Sutter pointed out, Exit’s work in other, related fields is just as, if not more important than its provision of physician-assisted suicide for its members. As the former Director of the German Federal Centre for Health Education Professor Dr Elisabeth Pott pointed out, the focus should not primarily be on offering physician-assisted suicide, but rather to create a health system where those in need are adequately taken care of. Professor Pott worried that an easing of assisted-dying legislation would prove an excuse for continuing to offer sub-par health care, especially in times of economic crisis. Professor Pott also stressed the importance of seeing the abilities, rather than limitations of individuals with chronic diseases.
Belgian doctor and cancer specialist Dr Benoît Beuselinck was also skeptical of the line of allowing physician-assisted suicide in Belgium, citing numbers that showed an increase in the number of assisted suicide cases where the patient was not terminally ill. While International Editor for The Economist Helen Joyce was quick to point out that even a perfect health system would never stop all individuals from wanting to end their life, she agreed that assisted dying should not become a fig leaf for poor health care provisions. The panel agreed on the important auxiliary functions of an organization like EXIT, but proved divided over whether or not physician-assisted suicide should be one of the components of end-of-life legislation.
Autonomy and dignity: Only for the patient?
When we speak about end-of-life issues we often evoke terms like autonomy and dignity. However, these terms are usually used in reference to the person at the end of his or her life, not in reference to those immediately affected by assisted suicide, such as the doctors or the family and friends of the individual in question. As Dr Beuselinck emphasized, putting a medical doctor in a position where he or she is forced to administer an assisted suicide would be unconscionable.
He stressed that while we must be respectful of an individual’s wish at the end of his or her life, we must also see this individual in a greater societal context where an assisted suicide would also impact others. He therefore argued in favor of upholding the right of doctors to deny undertaking the procedure of assisted suicide, or even in referring patients to other doctors who administer physician-assisted suicides.
A global perspective on dying
The majority of the world’s countries do not allow for assisted-dying as a part of end-of-life legislation. There are however bright examples of how assisted-dying can be included in comprehensive end-of-life legislation which includes strict guidelines on the circumstances under which it can be administered. Switzerland is one such example, but U.S. states such as California and Oregon are others.
Asked how they see the future of end-of-life legislation, all panelists stressed a need for further discussions and exchange across borders on how to best legislate this sensitive issue. As Helen Joyce pointed out, the bedrock of legislation has to be respectful and nuanced discussion, where neither side of the argument is villainized. As legislation evolves, in Germany and elsewhere, this debate certainly requires greater attention.