Abstract

The end of life is a topic that gives rise to reflection in many countries. Assisted suicide and euthanasia are currently at the heart of debates in France, where it is planned to legislate on this subject in the course of 2024. Indeed, despite an obvious advance in the palliative care of patients with severe health problems, some of them wish to turn to another option. Belgium allows euthanasia, which is therefore carried out by doctors. This is also the case in some provinces in Canada, where this accounts for about 7% of deaths. In Switzerland, assisted suicide is legal and practiced by associations. Euthanasia is a criminal offence. Forensic pathologists are concerned by assisted suicide because it is recognized as a non-natural death. This subject is not much discussed in international medical literature, probably because only a few countries allow its practice.

Keywords: Criminal; Professions

Swiss Legislation

Article 115 of the Code of Criminal Procedure (SCC) Incitement and Assistance to Suicide. Any person who for selfish motives incites or assists another to commit or attempt to commit suicide is, if that other person thereafter commits or attempts to commit suicide, liable to a custodial sentence not exceeding five years or to a monetary penalty. The Swiss Criminal Code (SCC) condemns euthanasia (Article 114 SCC), which is considered “murder at the request of the victim”. Such an act shall be punishable by a prison term not exceeding five years or by a monetary fine. On the other hand, Swiss legislation is very liberal when it comes to assisted suicide. Indeed, only a contradictory interpretation of Article 115 of the Code of Civil Procedure regulates this practice. It should be remembered that this law, which dates from 1942, was not at all drafted with a physician-assisted suicide state of mind, but in a desire to die due to a loss of honor, state of mind. Thus, assisted suicide is not punishable in the case of a person capable of discernment who ends his or her life, provided that the person accompanying him or her is not motivated by a selfish motive. Although this may seem surprising, and this question arises regularly from neighboring countries, this broad legislative openness does not in any way lead to the existence of abuses [1-3].

Ethical Aspects

Assisted suicide is carried out by doctors, either working for an association (see below) or practicing privately, for example the doctor treating the patient concerned. These professionals are subject to certain medico-ethical rules laid down by the organization of the medical professions, namely the Swiss Academy of Medical Sciences (SAMS). This entity has drafted guidelines on various topics that may raise ethical problems, and on the issue of end-of-life care and assisted suicide. These guidelines, the latest version of which dates from 2018, with an adaptation in 2021, set out certain requirements for the practice of physician-assisted suicide, namely:
•Capacity for discernment: The patient is capable of discernment in relation to assisted suicide.
•Independent will: the desire to die is well thought out, it is not the result of external pressure, and it is persistent.
•Extreme suffering: the patient’s symptoms and/or functional limitations have reached an extreme degree, and this feeling must be objectified by a diagnosis or prognosis to that effect.
•Consideration of alternatives: Indicated treatment options as well as other offers of help and support were sought, then explained and offered to the patient, but failed or were refused by the patient capable of discernment in this regard [4-9].

Associations

As the framework for assisted suicide is defined in this way in Switzerland, several associations offer this practice. Switzerland is politically organized into cantons, which must comply with federal legislation, but remain sovereign for a certain number of decisions; In addition, the country is divided for linguistic reasons into 3 main regions, respectively German-speaking, Italianspeaking, and French-speaking, the largest in terms of area and population density being German-speaking Switzerland, followed by French-speaking Switzerland. There are 4 main assisted suicide associations, namely Dignitas, Life Circle, EXIT German-speaking Switzerland and EXIT ADMD French-speaking Switzerland (hereinafter EXIT). Each is autonomous in its operation, in compliance with the legal and ethical requirements set out above. It is also important to note that any doctor can practice assisted suicide if he complies with legal and ethical requirements. For this reason, there’s no need for an association to intervene. Despite this extreme liberty, almost all the assisted suicides which refer to justice are performed by associations. EXIT German-speaking Switzerland has more than 150,000 members, who can either be domiciled in Switzerland or Swiss nationals residing abroad. Dignitas offers a service for people from countries where assisted suicide is not allowed and who wish to travel to Switzerland to end their lives. Most of them are from the United States, Germany or the United Kingdom[10-13].

EXIT French- speaking has more than 33,000 members. This number is increasing every day, probably due to a population that is not only growing, but also aging, with serious illnesses and/or disabilities that impair their quality of life. Many of these people joined the association to support its mission but never used its services. EXIT was founded in 1982 and initially worked hard to ensure that the obligation to comply with advanced directives was recognized. It wasn’t until the early 2000s that the practice of assisted suicide was established. Little by little, the structure has been equipped with an operation that allows it to cope with a growing demand for assisted suicide. This structure imposes its own requirements, which must, however, meet legal criteria and ethical recommendations. Thus, a person can benefit from assisted suicide if he or she is a member of the association (regardless of the duration of this affiliation), domiciled in Switzerland, of legal age, capable of discernment and suffers from either an incurable illness, intolerable suffering, or disabling paleopathology’s related to age. After careful consideration, this last criterion was added a few years ago, to compensate for an increase in life expectancy, but the quality of which may leave something to be desired. In view of a very permissive legislation, these criteria are dictated by the ASSM Guidelines [1,2].

In practice, when the EXIT association is approached by one of its members for assisted suicide, a doctor will initially have to validate the request file, ensuring that the criteria are met; then another doctor will examine the patient to prescribe pentobarbital. It is only after these steps and verifications that an accompanying person will meet with the patient, before setting, if necessary, the date scheduled for the accompaniment. Not all requests are successful: sometimes the patient dies from his pathologies beforehand; sometimes, the fact of having taken the steps reassures the patient and allows him to continue his life a little longer in a more serene way. The procedure is that once the death has been confirmed, the police and a forensic pathologist will visit the death scene to ensure that the medico-legal criteria have been met. In almost all cases, the body is immediately handed over to the family for funerals. Most of the accompaniment takes place at the patient’s home. However, there has been an opening in medico-social establishments as well as hospitals.

Medico-Legal Concern

Assisted suicide must be considered as a non-natural death, as the direct cause of death is a pentobarbital intoxication. This is the case even for a patient who is suffering from terminal cancer situation, with a life-threatening condition. For this reason, the forensic pathologist is concern, as he must perform a medicolegal examination of the body, to ensure no other cause of death could be suspected. His duty also consists, in common with the police, in evaluating if the ethical and legal conditions required are present, such as a pathological diagnosis entailing extreme suffering. Switzerland being divided in cantons, each one deal with assisted suicide differently. In the French-speaking part of the country, considering the corpse examination, most of the time the prosecutor won’t need order a complete autopsy as the associations performing assisted suicide is serious and reliable [14,15].

Conclusion

It is interesting to note that, despite extremely liberal legislation, Switzerland does not see any abuse in the practice of assisted suicide. It is essentially governed by ethical guidelines, to which the doctors are concerned comply. Morals have evolved and the practice of assisted suicide, which less than a decade ago was the subject to a lot of controversy, particularly among health professionals, is no longer really questioned. A form of collaboration has even developed with hospital palliative care teams, aware that, despite optimal care, the patients suffering can lead them to want to put an end to an existence that they no longer consider dignified. The police and the justice can count on reliable associations performing assisted suicide, which allows simple procedures, of course with respect to the medico-legal requirements but also with respect of the deceased’s families. It is important to realize that, even the subject of assisted suicide is being more and more discussed especially in the medical fields, it only concerns about 3 percent of the cause of deaths in Switzerland.

References

1. (2022) Attitude towards the end of life and death. ASSM Medico-Ethical Guidelines.
2. ch. 28 mars 2023
3. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J (2016) Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA 316(1): 79-90.
4. Agnes van der Heide (2013) Assisted suicide and euthanasia. Handb Clin Neurol 118: 181-189.
5. exit-romandie.ch
6. La Harpe R (1995) Suicide à Genève : 1971-1995. Journal de Médecine Légale Droit Médical 47: 291-295.
7. La Harpe R, Palmiere C, Shiferaw K, Burkhardt S (2005) Trente ans de suicide à Genève : é Journal de Médecine Légale Droit Médical 48: 488-494.
8. Burkhardt S, Sobel J, La Harpe R, Harding TW (2007) Euthanasia and assisted suicide: comparison of legal aspects in Switzerland and other countries. Med Sci Law 46(4): 287-294.
9. Burkhardt S, Sobel J, La Harpe R (2007) L’assistance au suicide en Suisse romande: une étude sur 5 ans. Journal de Médecine Légale Droit Médical 50: 41-44.
10. Zare M, Palmiere C, Sobel J, La Harpe R, Burkhardt S (2007) L’assistance au suicide en Suisse dans le contexte de polypathologie invalidante irréversible. Revue médicale suisse 3(128): 2434-2437.
11. BurkhardtS, Wyss K, La Harpe R (2007) L’assistance au suicide en Suisse: la position des mé Revue médicale suisse 3: 2861-2864.
12. Burkhardt S, Sobel J, La Harpe R (2007) Legal aspects and practice of assisted suicide in Switzerland. Supportive care in cancer 15(6).
13. Burkhardt S, La Harpe R (2009) Assistance au suicide: le rôle du médecin lé Journal suisse d’éthique biomédicale 2: 27-28
14. Burkhardt S, La Harpe R (2012) Debates about assisted suicide in Switzerland. Am. Forensic Med Patholo 33(4): 410-413.
15. Steck N, Egger M, Maessen M, reich T, Zwahlen M (2013) Euthanasie et suicide assité dans certains pays européens et Etats américains: revue systématique de la littérature. Soins mé Octobre 51(10): 933-944.