Abstract
In Switzerland, the practice of lay right-to-die societies (RTDS) organizing assisted suicide (AS) is tolerated by the state. Patient counseling and accompaniment into the dying process is overtaken by RTDS lay members, while the role of physicians may be restricted to prescribing the mortal dose after a more or less rigorous exploration of the patient’s decisional capacity. However, Swiss health care facilities and professionals are committed to providing suicide prevention. Despite the liberal attitude in society, the legitimacy of organized AS is ethically questioned. How can health professionals be supported in their moral uncertainty when confronted with patient wishes for suicide? As an approach towards reaching this objective, two ethics policies were developed at the Basel University Hospital to offer orientation in addressing twofold and divergent duties: handling requests for AS and caring for patients with suicidal thoughts or after a suicide attempt. According to the Swiss tradition of “consultation” (“Vernehmlassung”), controversial views were acknowledged in the interdisciplinary policy development processes. Both institutional policies mirror the clash of values and suggest consistent ways to meet the challenges: respect and tolerance regarding a patient’s wish for AS on the one hand, and the determination to offer help and prevent harm by practicing suicide prevention on the other. Given the legal framework lacking specific norms for the practice of RTDS, orientation is sought in ethical guidelines. The comparison between the previous and newly revised guideline of the Swiss Academy of Medical Sciences reveals, in regard to AS, a shift from the medical criterion, end of life is near, to a patient rights focus, i.e., decisional capacity, consistent with the law. Future experience will show whether and how this change will be integrated into clinical practice. In this process, institutional ethics policies may—in addition to the law, national guidelines, or medical standards—be helpful in addressing conflicting duties at the bedside. The article offers an interdisciplinary theoretical reflection with practical illustration.
Highlights
In the last decades, Switzerland has gained the reputation of being unique with regard to the practice and tolerance of assisted suicide (AS)—unique in comparison to other liberal states, e.g., the Benelux states permitting euthanasia and physician-assisted suicide
The legal basis for AS is regulated by Art. 115 StGB [14]: immunity from punishment for assisting in the suicide of a patient requires (1) the person being assisted in suicide to have decisional capacity and (2) that suicide is committed by choice and inheriting authority of action, i.e., control (“Tatherrschaft”)—the latter requiring that the actions leading to suicide and death be performed fully by the patient
It has been shown in the paper that the coexistence of tolerance for assisted suicide (AS) in Swiss society and the necessity to provide suicide prevention creates a tension between the underlying values and may trigger ethical uncertainty among health care professionals: When does a patient deserve respect, or even support, for the wish to die by terminating his or her life, and when is it the primary duty to hinder a person from committing a suicidal act—and how should this be done? Questions such as these reveal the basically controversial and value-laden nature of suicide that does not allow for a simple answer
Summary
Switzerland has gained the reputation of being unique with regard to the practice and tolerance of assisted suicide (AS)—unique in comparison to other liberal states, e.g., the Benelux states permitting euthanasia and physician-assisted suicide. It addresses strategies to promote wellbeing for the patient, his or her family, and the nurse In this theoretical article, we will describe the twofold requirements for clinical and nursing staff: corresponding with policy 2, to build up competencies of responding appropriately to suicidal patients, i.e., taking necessary decisions and actions, and, corresponding with policy 1, to develop the capability to communicate in a respectful and empathic manner with patients requesting AS, acknowledging their personality and the liberal societal context of Switzerland, even if (morally) disapproving the choice. The approaches of policy development will be described as well as the respective policy content Their practical relevance will be illustrated by authentic clinical vignettes highlighting the need of health care professionals for guidance when facing issues of suicide, here: by an institutional policy. Development of Two Institutional Policies: (1) On Assisted Suicide and (2) On
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