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Education and debate
Assisted suicide and euthanasia in Switzerland:
allowing a role for non-physicians
Samia A Hurst, Alex Mauron
Switzerland has an unusual position on assisted suicide: it is legally condoned and can be performed
by non-physicians. Euthanasia is illegal, but there is a debate about decriminalisation that also
discusses participation by non-physicians
The involvement of a physician is usually considered a
necessary safeguard in assisted suicide and euthanasia.
Legislation in Holland, Belgium, and the US state of
Oregon all require it, as did the legalisation of
euthanasia in Australia’s Northern Territories.
1–4
Physi-
cians are trusted not to misuse these practices; along
with pharmacists they are in control of prescription
drugs. Physicians are believed to know how to ensure a
painless death, and they are in a position to offer
palliative care knowledgeably.
Switzerland seems to be the only country in which
the law limits the circumstances in which assisted
suicide is a crime, thereby decriminalising it in other
cases, without requiring the involvement of a physician.
Consequently, non-physicians have participated in
assisted suicide. The law has explicitly separated the
issue of whether or not assisting death should be
allowed in some circumstances, from that of whether
physicians should do it. This separation has not
resulted in moral desensitisation of assisted suicide and
euthanasia.
Methods
We describe the history of the Swiss law for assisted
suicide, the current debate, and the existing data on
euthanasia and assisted suicide in Switzerland. This
review is based on the relevant literature and on the
experience of participants in these debates.
History of the Swiss law
In 1918, a comment by the Swiss federal government
on the first federal penal code stated: “In modern penal
law, suicide is not a crime . . . Aiding and abetting
suicide can themselves be inspired by altruistic motives.
This is why the project incriminates them only if the
author has been moved by selfish reasons.”
5
At the
time, the attitudes of the Swiss public were shaped by
suicides motivated by honour and romance, which
were considered to be valid motives. Motives related to
health were not an important concern, and the
involvement of a physician was not needed. Euthanasia
for terminally ill patients, although intensely discussed
in the United States and the United Kingdom in the
1900s, seems not to have been debated in 1918 in
Switzerland.
6
Assisted suicide
Article 115 of the Swiss penal code considers assisting
suicide a crime if and only if the motive is selfish. It
condones assisting suicide for altruistic reasons.
7
In
most cases the permissibility of altruistic assisted
suicide cannot be overridden by a duty to save life.
8
Article 115 does not require the involvement of a phy-
sician nor that the patient be terminally ill. It only
requires that the motive be unselfish. This reliance on a
base motive rather than on the intent to kill to define a
crime is foreign to Anglo-Saxon jurisprudence, but it
can be pivotal in continental Europe.
9
Swiss law does not consider suicide a crime or
assisting suicide as complicity in a crime. It views
suicide as possibly rational. Also, it does not give physi-
cians a special status in assisting it. When an assisted
suicide is declared, a police inquiry is started, as in all
cases of “unnatural death.” Since no crime has been
committed in the absence of a selfish motive, these are
mostly open and shut cases. Prosecution happens if
doubts are raised on the patient’s competence to make
an autonomous choice. This is rare.
Summary points
Most legislation condoning assisted suicide or
euthanasia stipulates that a physician must be
involved
The acceptability of voluntary death is not entirely
contained within the framework of medicine
Assisted suicide is not a criminal act under Swiss
law if it is motivated by altruistic considerations
Sharp controversy surrounds assisted suicide in
Switzerland, but the few data that exist suggest
that the public supports it
Department of
Clinical Bioethics,
National Institutes
of Health, Bethesda,
MD 20892-1156,
USA
Samia A Hurst
postdoctoral fellow
Unité de Recherche
et d’Enseignement
en Bioéthique,
Faculty of Medicine,
University of
Geneva, Switzerland
Alex Mauron
professor
Correspondence to:
S A Hurst
shurst@cc.nih.gov
BMJ 2003;326:271–3
271BMJ VOLUME 326 1 FEBRUARY 2003 bmj.com
Euthanasia
Swiss law does not recognise the concept of
euthanasia. “Murder upon request by the victim”
(article 114 of the Swiss penal code) is considered less
severely than murder without the victim’s request, but
it remains illegal. Following a proposal to the Swiss
parliament to decriminalise euthanasia, in 1997 the
federal government commissioned a working group
which included specialists in law, medicine, and ethics
to examine the issue. This group recommended that
euthanasia remain illegal. Most of the group, however,
proposed decriminalising cases in which a judge was
satisfied that euthanasia followed the insistent request
of a competent, incurable, and terminally ill patient in
unbearable and intractable suffering. This explicitly
included euthanasia performed by non-physicians, as
they would not be committing a greater transgression
than physicians. It was considered dangerous to create
legal circumstances where a non-physician helper
would have to be prosecuted whereas the physician
would not. Some members of the group opposed
decriminalising euthanasia.
10
Despite this report,
parliament voted not to go ahead with the proposed
legislation, and a change is unlikely in the near future.
The Swiss National Advisory Commission on Bio-
medical Ethics is debating these issues. Its position
cannot be predicted.
The physician’s role
The Swiss Academy of Medical Sciences states in its
ethical recommendations that assisted suicide is “not
a part of a physician’s activity.”
11
This statement is
ambiguous. It has usually been understood to mean
that physicians should not assist suicide and was para-
phrased in 2002 in a joint statement by the Swiss
Medical Association and the Swiss Nurses Associ-
ation.
12
But the statement from the Swiss Academy of
Medical Sciences has also been understood to place
assisted suicide outside the purview of professional
oversight, and to refer physicians, as citizens, to the law.
This allows them, like other citizens, to altruistically
assist suicide.
13
In fact, even if it is understood to
discourage physicians from assisting suicide, legally it
leaves physicians with the same discretion as any
citizen to altruistically assist suicide.
In practice, many physicians oppose assisted
suicide and euthanasia, and hospitals have barred
assisted suicide from their premises. Some physicians,
however, do assist suicides and some advocate the
decriminalisation of euthanasia. The arguments
advanced are the same as in other countries.
Opponents argue that killing patients violates physi-
cians’ professional integrity and endangers the doctor-
patient relationship.
14
Proponents see assisted suicide
and euthanasia as part of a caring response to intracta-
ble human suffering.
15
In 2001, the Swiss parliament
rejected a bill that would have barred physicians from
assisting suicide.
The importance of palliative care is acknowledged.
Resources for palliative care in Switzerland are not yet
available to all terminally ill patients. This remains a
strong argument against decriminalising euthanasia.
16
It is also an argument against assisted suicide and an
important point in the public controversy.
Data on attitudes and practices
Assisted suicide is a controversial topic in Switzerland,
but data on public attitudes towards assisted suicide
and euthanasia are scarce. According to one survey,
half of 2411 army conscripts were willing to “shorten
the life of a family member who suffered too much and
who asked for euthanasia.”
17
In a 1999 survey of the
Swiss public, 82% of 1000 respondents agreed that “a
person suffering from an incurable disease and who is
in intolerable physical and psychological suffering has
the right to ask for death and to obtain help for this
purpose.” Of these, 68% considered that physicians
should provide this help; 37% considered that the fam-
ily, 22% that right to die societies, 9% that nurses, and
7% that religious representatives should be able to ful-
fil such requests. Legislation to allow euthanasia was
favoured by 71% of all respondents.
18
No data are
available on how well people believe the existing
system is working in practice, even though this is one of
the key points in the controversy.
In another survey, 73% of 90 physician members of
the Swiss Association of Palliative Care opposed the
legalisation of euthanasia. However, 19% stated that
they would practice it if it became legal.
19
This small
support for euthanasia contrasts with the position of
the European Association for Palliative Care.
20
No sur-
vey has been conducted on the Swiss medical
profession as a whole.
No validated statistics exist for assisted suicides in
Switzerland. These deaths are not differentiated from
unassisted suicides in official records. According to the
president of one of the Swiss right to die societies,
around 1800 requests for assisted suicides are made
each year. Two thirds are rejected after screening. Half
of the remaining people die of other causes, leaving
about 300 suicides assisted by these societies annually.
This constitutes around 0.45% of deaths in Switzerland
(J Sobel, personal communication, 2002).
21
Individuals
outside these societies may assist additional suicides. In
comparison, reported assisted suicide in Oregon
represents 0.09% of deaths, and other US data showed
a rate of assisted suicide and euthanasia of 0.4% among
terminally ill patients.
22 23
The rate of assisted suicide in
the Netherlands is 0.3%, lower than the estimate for
Switzerland.
24
Reginald Crew, who had motor neurone disease, travelled from
Britain to Switzerland to end his life
MARTIN TUCKETT/PA
Education and debate
272 BMJ VOLUME 326 1 FEBRUARY 2003 bmj.com
Conclusion
Altruistic assisted suicide by non-physicians is legal in
Switzerland. This has led to a unique situation. It has
separated issues that are sometimes conflated.
Whether assisted voluntary death should ever be
allowed has been discussed without being exclusively
linked to physicians. Physicians have separately
debated their appropriate role at the end of life. They
have a part to play in both debates.
Assisted suicide and euthanasia ask questions that
cannot be answered from the perspective of medicine
alone. An incompatibility between assisting voluntary
death and the professional ethos of physicians may
mean that physicians should not assist death, but it
does not necessarily settle the argument of whether
anyone ever should. The controversy has remained
intense. Acceptance of assisted suicide seems to be
growing, but support for palliative care is growing also,
as end of life issues are kept in the public eye. Further
empirical analysis of this situation is important. This
debate could continue to yield insights into the issues
around suffering at the end of life.
Note added in proof
—
Recently, the practice of one
Zurich based right to die society that offers assisted sui-
cide to non-resident foreigners has attracted a great
deal of media attention and concern. This could even-
tually result in increased regulation, but a radical
departure from Switzerland’s unique stance on this
issue seems unlikely.
We thank Ezekiel Emanuel, Dan Brock, Frank Miller, and David
Wendler for their invaluable criticism of the manuscript; Ursula
Cassani, Marianne Cherbuliez, Claudia Mazzocato, Jerome
Sobel, Frederic Stiefel, and Marinette Ummel for providing
information; and Clive Seal for a thoughtful and constructive
review. The views expressed here are the authors’ own and do
not reflect the position of the National Institutes of Health or of
the Department of Health and Human Services.
Contributors: Both authors contributed to the conception of
this paper and to the literature review. SAH wrote the first draft
and AM made important contributions to all subsequent drafts.
SAH will act as guarantor.
Funding: SAH is supported by a grant from the Oltramare
Foundation, Geneva, Switzerland. The views expressed here are
those of the authors and not necessarily those of the Oltramare
Foundation.
Competing interests: AM is a member of the Swiss National
Advisory Commission on Biomedical Ethics. The views
expressed here do not necessarily reflect those of the
commission.
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(Accepted 17 January 2003)
“I think I need a psychiatrist”
A substantial number of patients attending general neurology
outpatient clinics have neurologically unexplained symptoms.
Psychological and psychiatric factors may be implicated in the
genesis and maintenance of many of these symptoms, but the
patients are often unwilling either to accept such explanations or
to contemplate therapeutic approaches based on them. It is
therefore notable to hear a patient open a neurology consultation
by stating, “I think I need a psychiatrist.”
The man, in his 30s, complained of difficulty controlling his
dominant hand. He first noticed this when playing darts: his
arrows kept shooting off in unexpected directions and
jeopardising the safety of bystanders. Involuntary supination of
the hand also became evident when he tried using a knife or
scissors and when writing. A diagnosis of focal dystonia was
made, and injections of botulinum toxin were offered.
“I think I need a psychiatrist.” It might be argued that this
opening gambit reflected the patient’s diffidence or anxiety,
perhaps intended to forestall a perceived fear of wasting the
neurologist’s time. However, this was an intelligent person who
had clearly thought about his symptoms and, in attempting to
find an explanation for them, genuinely thought that a
psychiatrist might be the most appropriate source of help. He had
already consulted a hypnotist. In this context it is worth noting
that until quite recent times neurologists considered dystonic
syndromes to be of psychiatric, functional, or non-organic origin.
Just as neurologists are on the lookout for psychiatric illness
presenting with somatic symptoms, the lesson I draw from this
case is to look hard for neurological illness in those (admittedly
rare) patients arriving in the neurology clinic professing a need
for a psychiatrist.
Andrew Larner consultant neurologist, Walton Centre for Neurology
and Neurosurgery, Liverpool
Education and debate
273BMJ VOLUME 326 1 FEBRUARY 2003 bmj.com
