TABLE 1.

The development of the legal and medical-ethical framework conditions of assisted suicide in Switzerland (Zurich, Switzerland, 2023).

The Criminal Code: The Swiss model of AS was developed in the 1980s and designed with a framework that included comparatively open legal regulations in the first half of the last century [14–17]. According to Article 115 of the Swiss Criminal Code, which entered into force in 1942, AS is only illegal in cases where it is carried out “for selfish motives” [30].

In contrast, direct active euthanasia, i.e., killing on request, even if requested seriously and insistently, is a criminal offence according to the Articles 111 (“Intentional homicide”), 113 (“Manslaughter”) and 114 (“Homicide at the request of the victim”).

The Swiss Academy of Medical Sciences (SAMS): Since the Swiss legislature initially did not enact specific regulations for organized medical aid in dying (in particular a legal framework for AS), most recently in a consultation in 2011, and Swiss courts grant the medical profession a high degree of personal responsibility in the question of AS, the medical authorities had to formulate binding rules for themselves about this issue.

This social and medico-ethical development process had been adopted by the SAMS. This institution, founded in 1943, sees itself as a bridge builder between science and society. The activity of the SAMS is, among others, directed on the “clarification of ethical questions in connection with medical developments and their effects on society” [31]. As a rule, the guidelines developed by the SAMS are incorporated as an ethics protocol into the Swiss Medical Association (Foederatio Medicorum Helveticorum, FMH) Code of Professional Conduct and are thus binding for its members.

The SAMS guidelines for AS have changed over time from categorical rejection to a more flexible stance.

For a long time, the SAMS kept a low profile with regard to this topic. With the opinion that AS is “not a part of medical practice” because it contradicts the goals of medicine, further statements on the subject were not even considered necessary.

Then, in 2004, a revision of the “End-of-life care” guidelines was provided. Here, it was stated for the first time that a physician may, on the basis of a personal decision of conscience, assist in suicide if there is a serious disease that will lead to death in the foreseeable future [32].

During the following years, however, the right-to-die organizations in Switzerland have always gone further in assisting those who wish to die. The principle that a disease leading to death in the foreseeable future is imperative for the approval of AS was never considered binding by them. For many years, EXIT, which is the largest right-to die organization in the country, has propagated “old age assisted suicide” for elderly people in cases “when the sum of their pain and infirmity is perceived as an unbearable state of suffering” [33].

In 2018, the SAMS revised its recommendations on medical aid in dying (“Management of dying and death”) [34]. The key criteria for the medical profession to participate in AS was now no longer that the final phase of life, but that “symptoms of disease and/or functional impairments” are present, which are the “source of intolerable suffering.”

For more than 4 years, however, the FMH refused to adopt this updated version as a professional ethics guideline in its statutes. The representatives of the FMH criticized that the revised recommendations represent a “massive expansion of the scope of (...) permissible assisted suicide” and clearly depart from their original objective to help only terminally ill people” [35]. The core of the criticism, however, was that allowing AS for people who perceive their suffering as unbearable would mean considerable uncertainty for the physicians concerned, and that the revised guidelines would make it difficult for them to define clear limits for their participation in AS, since the term “intolerable suffering” is too vague and depends heavily on the patient’s subjective assessment. Thus, for many years, a smoldering conflict situation existed in Switzerland with regard to medical ethics and professional law.

In order to put an end to this unsatisfactory state of affairs, the SAMS and the FMH set up a joint working group in 2021, which once again revised the medical-ethical guidelines on AS. The updated version of the new recommendations includes a few specifications (e.g., in the subchapters “Capacity” and “Autonomous wishes”), but above all the recognition that well-documented “severe suffering” is sufficient as a criterion for granting AS [34]. The FMH adopted the reformulated document in May 2022; as a result, the revised guidance was incorporated as a code of ethics into the FMH Code of Professional Conduct [35].

Note: The legal framework for AS is not defined by the SAMS Guidelines, but by the Swiss Criminal Code (Strafgesetzbuch) and the Federal Narcotics and Therapeutic Products Acts. The SAMS guidelines are medical-ethical guidelines and have no immediate legal force.

The high level of social acceptance: The current practice of AS is widely accepted among those living in Switzerland. This was mirrored in the results of a referendum that was held in Canton of Zurich in May 2011, titled “Stop Assisted Suicide”, which was intended to put an end to the practice. The proposal was rejected by 84% of the vote [19].

Interaction between medical and non-medical responsibilities: In the practical application of AS a close interaction between medical and non-medical responsibilities has developed [14–17].

The non-medical responsibilities have been taken over by the staff of the various right-to-die organizations. The role of the doctor in this process consists principally in the prescription of a lethal dose of sodium pentobarbital after careful assessment of the underlying disease and the capacity of judgement of the patient. During the suicide itself as a rule a member of staff of the right-to-die organization is present but not necessarily the doctor.

After the onset of death, the AS must be reported to the authorities as an “extraordinary death.”

AS, Assisted suicide; FMH, Swiss Medical Association (Foederatio Medicorum Helveticorum); SAMS, Swiss Academy of Medical Sciences.