Assisted suicide raises medical, legal, and ethical questions. This FAQ provides an overview of key aspects of assisted suicide in Switzerland – from the legal framework and the role of the medical profession to questions of decision-making capacity and the perspective of relatives.
What is the procedure for assisted suicide? Is a physician always involved?
In general, it is a physician who assesses whether the four requirements specified in the SAMS guidelines for assisted suicide are met (capacity, self-determination, intolerable suffering, consideration of alternatives – see Assisted suicide for details). The prescription for the lethal drug (PBS) can only be issued by a physician. In Switzerland, an assisted suicide organisation is usually responsible for coordination of the whole process.
A physician is not generally directly involved when assisted suicide takes place; instead, a volunteer from the assisted suicide organisation is present to provide support. The final action in the process leading to death must always be performed by the person wishing to die – i.e. they must drink the lethal preparation or initiate the infusion themselves.
Any death resulting from assisted suicide must be reported as an «unnatural death». The competent authorities arrange for the necessary investigations to be carried out.
What does the provision of assisted suicide mean for the medical profession?
This activity involves a high degree of responsibility. Discussions with the person seeking suicide are of crucial importance. Physicians must ensure that the person concerned (1) has capacity; (2) is aware of, and has been offered, alternatives; and that (3) their desire for death is self‑determined, well-considered and enduring, and not due to external pressure.
In the SAMS guidelines, prescription of the lethal drug (PBS) is subject to a fourth condition: (4) there must be medically definable severe symptoms of disease and/or functional impairments, causing intolerable suffering in the person concerned. This suffering and the person’s consequent wish to end their own life must be comprehensible for the physician. This comprehensibility is of central ethical importance: anyone prescribing a lethal substance must be certain, in each individual case, that this is a responsible action, since by issuing the prescription the physician is contributing directly to the ending of a life.
Medical participation in assisted suicide is ethically and professionally compatible with physicians’ understanding of their role if medically definable symptoms of disease and/or functional impairments are the reason for the suffering which is felt to be intolerable. Physicians are not, however, obliged to provide assisted suicide or to propose it as an option. Each physician will decide for themselves whether this activity is compatible with their own understanding of their professional role.
Is end-of-life care the same as assisted suicide?
No. The term «end-of-life care» has a different meaning: this is what is provided on a daily basis by nurses, physicians and caring relatives supporting people who are approaching the end of their lives. End-of-life care in the sense of palliative care (available in French and in German) aims to provide comprehensive alleviation of distressing symptoms in people who are terminally ill. The focus is not on shortening life, but on preserving autonomy, dignity and quality of life right up to the end.
The term «end-of-life care» should therefore not be used for assisted suicide.
Who opts for assisted suicide and where does it take place?
In Switzerland, the great majority of people who die with assisted suicide are aged over 64, with significantly more women than men. Around 40% are suffering from cancer, 10–15% from neurological diseases and the same proportion from cardiovascular disorders. A third have other conditions, including dementia and depression.
Assisted suicide almost always takes place at home, i.e. in a private apartment or care home. However, professionals working in hospitals and psychiatric clinics are also confronted with enquiries about assisted suicide. Some cantons have introduced binding regulations to ensure that assisted suicide can be performed in hospitals, psychiatric clinics and care/nursing homes. In other cantons, some healthcare facilities have their own internal guidelines: some prohibit assisted suicide on site, others tolerate it under certain conditions.
Are people with a mental illness eligible for assisted suicide?
As the medical-ethical justifiability of assisted suicide according to the four criteria specified in the SAMS Guidelines (see above) is not restricted to particular diagnostic groups, it also applies to people with a mental disorder. It would be discriminatory to rule out the possibility of assisted suicide for this group solely on the basis of the diagnosis. It should be emphasised, however, that suicidality is a characteristic and treatable symptom of many mental disorders, and that the assessment of capacity in relation to assisted suicide in people with mental disorders poses particular professional and medical-ethical challenges.
A desire for death must always – i.e. also in the presence of a mental disorder – be taken seriously and discussed in depth. Addressing this topic is extremely demanding for both parties, but is indispensable in order to arrive at a decision that is coherent and justifiable both for the individual concerned and for the professional involved.
How is capacity assessed?
Given the implications of the decision, mental incapacity on the part of the person seeking assisted suicide must be particularly carefully excluded. Of relevance for the assessment are not only cognitive but also emotional, motivational and volitional factors. Physicians who are required to assess capacity can refer to the SAMS guidelines on «Assessment of capacity in medical practice». In addition to the exploratory discussions, these guidelines recommend the adoption of a standardised procedure for the evaluation of decision-making capacity and provide a tool U-Doc for this purpose.
How is the relatives’ perspective to be taken into account?
Assisted suicide affects not only the person directly concerned but also the people close to them. Against this background, the SAMS guidelines recommend that individuals desiring suicide should be encouraged to discuss their wishes with their relatives at an early stage. Relatives who themselves wish, or are requested by the person concerned, to support the process face considerable emotional challenges – for example, when it comes to the «right» time for the assisted suicide appointment.
Physicians must therefore always bear in mind that those close to the person concerned also require attention and support in this stressful situation. Before, during and after the performance of assisted suicide, consideration should be given to the needs of relatives and, if appropriate, the interprofessional care team and others closely involved; any support which may be required is to be made available and documented.
How is assisted suicide legally regulated at the federal level?
In Switzerland, there is no specific federal law regulating the details of assisted suicide. At the federal level, assisted suicide is only explicitly mentioned in criminal law. The Swiss Criminal Code (CC) restricts assisted suicide in Art. 115, by prohibiting assistance in suicide if it is provided for selfish motives. It is also a legal requirement that the final act leading to death must be performed by the person concerned him/herself. Otherwise, this would be a case of homicide at the victim’s request, which is an offence under Art. 114 CC.
If assisted suicide is to be permissible, the person concerned must have capacity. Only then does it qualify as suicide. Involvement in the death of a person who lacks capacity could possibly be regarded as intentional homicide, which is prohibited under Art. 111 ff. CC.
Also applicable for physicians issuing a prescription for the lethal drug (PBS) are the provisions of the Federal Narcotics Act.
In summary, this means that assisted suicide is not an offence in Switzerland if the person wishing to die has capacity and performs the act him/herself, and if the person providing support is not acting from selfish motives. In practice, however, assisted suicide is subject to tighter standards, defined not by law but through self-regulation (the rules of the assisted suicide organisations and the SAMS guidelines).
How is assisted suicide legally regulated at the cantonal level?
Only a few cantons have specific legal regulations on assisted suicide. Such provisions have been enacted by the cantons of Geneva, Vaud, Neuchâtel and Valais. These relate to assisted suicide in public institutions such as hospitals, psychiatric clinics and care/nursing homes. The cantonal laws define material requirements which must be met. In terms of content, these are largely in agreement with the four criteria specified in the SAMS guidelines. In addition, the cantonal laws regulate the specific procedure and formulate binding duties of care.
How has the position of the SAMS guidelines changed on assisted suicide?
The SAMS has been closely concerned with assisted suicide for many years. Over the last two decades, a notable development could be observed: in the guidelines on «Care of patients at the end of life» published in 2004, it was stated that assisted suicide could only be ethically justifiable «if the end of life is near». Through engagement with societal developments and in close consultation with the health professions concerned, medical-ethical reflection led to the revised guidelines.
The guidelines currently in force (2018, adapted in 2021) also discuss assisted suicide in relation to cases where death is not yet imminent. In these guidelines, assisted suicide is considered to be justifiable even when the end of life is not yet approaching but intolerable suffering is present. However, the wording used in the 2018 version gave rise to uncertainties in practice. The section on assisted suicide was therefore clarified in 2021. What was implicit in the 2018 version is now explicitly stated: under the guidelines, the performance of assisted suicide in persons who are healthy is not ethically justifiable. It may, however, be considered in cases where a person is experiencing intolerable suffering as a result of a medically defined severe disease or functional impairment, and treatment options have been exhausted or rejected.