Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 150 No. 2526 (2020)

Social, cultural and experiential patterning of attitudes and behaviour towards assisted suicide in Switzerland: evidence from a national population-based study

DOI
https://doi.org/10.4414/smw.2020.20275
Cite this as:
Swiss Med Wkly. 2020;150:w20275
Published
01.07.2020

Summary

Switzerland has the longest history of the legal practice of non-physician assisted suicide of any country. Assisted suicide is not very tightly regulated in Switzerland, and almost all assisted suicides are supported by a right-to-die organisation. Our study investigates older adults’ attitudes and behaviour towards assisted suicide, and the associations of these with the individuals’ sociodemographic and cultural characteristics, as well as with their own health status and healthcare-related experiences in Switzerland. We performed weighted prevalence and multivariable logistic regression estimation on a nationally representative sample of adults aged 55 and over from wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland (n = 2168). Overall, 81.7% of respondents supported the legality of assisted suicide, as is currently the case in Switzerland, and 60.9% stated that they would potentially consider asking for assisted suicide under certain circumstances; 28.2% of respondents reported either that they are already or that they are likely to become a member of a right-to-die organisation, with 4.9% of respondents reporting to already be a member of such an organisation at the time of the survey. Higher levels of education and previous experience as a healthcare proxy were positively associated with more favourable attitudes and behaviour towards assisted suicide. Compared to individuals aged 55–64, adults aged 65–74 generally showed more favourable attitudes and behaviour towards assisted suicide. By contrast, religious persons displayed more negative attitudes and behaviour towards assisted suicide. Attitudes towards assisted suicide were also more negative in the oldest age group (75+) in comparison to adults aged 55–64, and among persons living in French- and Italian-speaking Switzerland compared to those living in German-speaking Switzerland. While approval for assisted suicide is high overall in Switzerland, more vulnerable population groups, such as older or less educated individuals, have less favourable attitudes towards assisted suicide. In addition, cultural sensitivities to and personal experiences with death and dying are likely to shape the approval or rejection of assisted suicide as it is currently implemented in Switzerland.

References

  1. Materstvedt LJ, Clark D, Ellershaw J, Førde R, Gravgaard AM, Müller-Busch HC, et al.; EAPC Ethics Task Force. Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force. Palliat Med. 2003;17(2):97–101, discussion 102–79. doi:.https://doi.org/10.1191/0269216303pm673oa
  2. Andorno R. Nonphysician-assisted suicide in Switzerland. Camb Q Healthc Ethics. 2013;22(3):246–53. doi:.https://doi.org/10.1017/S0963180113000054
  3. Steck N, Egger M, Maessen M, Reisch T, Zwahlen M. Euthanasia and assisted suicide in selected European countries and US states: systematic literature review. Med Care. 2013;51(10):938–44. doi:.https://doi.org/10.1097/MLR.0b013e3182a0f427
  4. Schwarzenegger C, Manzoni P, Studer D, Leanza C. Was die Schweizer Bevölkerung von Sterbehilfe und Suizidbeihilfe hält. Jusletter. 2010.
  5. FSO. Suicide assisté selon le sexe et l'âge. T14.03.04.01.14 ed. Neuchâtel: Federal Statistical Office; 2016.
  6. Bosshard G, Fischer S, Bär W. Open regulation and practice in assisted dying. Swiss Med Wkly. 2002;132(37-38):527–34.
  7. Le Conseil fédéral. Soins palliatifs, prévention du suicide et assistance organisée au suicide. Berne: Conférdération suisse. 2011.
  8. Borasio GD. Suizidhilfe aus ärztlicher Sicht – die vernachlässigte Fürsorge. Schweiz Arzteztg. 2015;96(24):889–91. doi:.https://doi.org/10.4414/saez.2015.03545
  9. Borasio GD, Jox RJ, Gamondi C. Regulation of assisted suicide limits the number of assisted deaths. Lancet. 2019;393(10175):982–3. doi:.https://doi.org/10.1016/S0140-6736(18)32554-6
  10. Steck N, Zwahlen M, Egger M ; Swiss National Cohort. Time-trends in assisted and unassisted suicides completed with different methods: Swiss National Cohort. Swiss Med Wkly. 2015;145:w14153. doi:.https://doi.org/10.4414/smw.2015.14153
  11. Steck N, Junker C, Zwahlen M ; Swiss National Cohort. Increase in assisted suicide in Switzerland: did the socioeconomic predictors change? Results from the Swiss National Cohort. BMJ Open. 2018;8(4):e020992. doi:.https://doi.org/10.1136/bmjopen-2017-020992
  12. Steck N, Junker C, Maessen M, Reisch T, Zwahlen M, Egger M ; Swiss National Cohort. Suicide assisted by right-to-die associations: a population based cohort study. Int J Epidemiol. 2014;43(2):614–22. doi:.https://doi.org/10.1093/ije/dyu010
  13. Steck N, Egger M, Zwahlen M ; Swiss National Cohort. Assisted and unassisted suicide in men and women: longitudinal study of the Swiss population. Br J Psychiatry. 2016;208(5):484–90. doi:.https://doi.org/10.1192/bjp.bp.114.160416
  14. Gamondi C, Pott M, Payne S. Families’ experiences with patients who died after assisted suicide: a retrospective interview study in southern Switzerland. Ann Oncol. 2013;24(6):1639–44. doi:.https://doi.org/10.1093/annonc/mdt033
  15. Fischer S, Huber CA, Furter M, Imhof L, Mahrer Imhof R, Schwarzenegger C, et al. Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians. Swiss Med Wkly. 2009;139(23-24):333–8.
  16. GfK. Résumé des résultats de l'étude «Soins palliatifs». Berne: GfK Switzerland SA; 2009.
  17. Brügger B, Lalive R, Zweimüller J. Does Culture Affect Unemployment? Evidence from the Röstigraben. CESifo Working Paper Series. 2009;2714
  18. Gire J. How death imitates life: Cultural influences on conceptions of death and dying. Online Read Psychol Cult. 2014;6(2). doi:.https://doi.org/10.9707/2307-0919.1120
  19. Martín JM, Olano-Lizarraga M, Saracíbar-Razquin M. The experience of family caregivers caring for a terminal patient at home: A research review. Int J Nurs Stud. 2016;64:1–12. doi:.https://doi.org/10.1016/j.ijnurstu.2016.09.010
  20. Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med. 2011;154(5):336–46. doi:.https://doi.org/10.7326/0003-4819-154-5-201103010-00008
  21. van Wijmen MP, Pasman HR, Widdershoven GA, Onwuteaka-Philipsen BD. Motivations, aims and communication around advance directives: a mixed-methods study into the perspective of their owners and the influence of a current illness. Patient Educ Couns. 2014;95(3):393–9. doi:.https://doi.org/10.1016/j.pec.2014.03.009
  22. Benatar D. A legal right to die: responding to slippery slope and abuse arguments. Curr Oncol. 2011;18(5):206–7. doi:.https://doi.org/10.3747/co.v18i5.923
  23. Givens JL, Mitchell SL. Concerns about end-of-life care and support for euthanasia. J Pain Symptom Manage. 2009;38(2):167–73. doi:.https://doi.org/10.1016/j.jpainsymman.2008.08.012
  24. Verbakel E, Jaspers E. A Comparative Study on Permissiveness Toward Euthanasia: Religiosity, Slippery Slope, Autonomy, and Death with Dignity. Public Opin Q. 2010;74(1):109–39. doi:.https://doi.org/10.1093/poq/nfp074
  25. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79–90. doi:.https://doi.org/10.1001/jama.2016.8499
  26. Börsch-Supan A. Survey of Health, Ageing and Retirement in Europe (SHARE) Wave 6. Release version: 6.1.1. In: SHARE-ERIC, editor.2018.
  27. SHARE. End-of-life questionnaire. Munich: Max Planck Institute for Social Law and Social Policy (MEA); 2015 [cited 2018 April 14]; Available from: http://www.share-project.org/fileadmin/pdf_questionnaire_wave_6/DO_EN_SHARE_04.12.2014corr.pdf.
  28. UNESCO. International Standard Classification of Education ISCED 1997. Paris: United Nations Educational, Scientific and Cultural Organization; 2006.
  29. Egli S, Mayer B, Mast F, eds. Cultural differences and similarities among German-, French- and Italian speaking Switzerland and neighboring countries. 15th Swiss Psychological Society Conference; 2017; Lausanne.
  30. Laesser C, Beritelli P, Heer S. Different native languages as proxy for cultural differences in travel behaviour: insights from multilingual Switzerland. Int J Cult Tour Hosp Res. 2014;8(2):140–52. doi:.https://doi.org/10.1108/IJCTHR-02-2014-0010
  31. Little RJA. A Test of Missing Completely at Random for Multivariate Data with Missing Values. J Am Stat Assoc. 1988;83(404):1198–202. doi:.https://doi.org/10.1080/01621459.1988.10478722
  32. Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley and Sons; 1987.
  33. Cohen J, Van Landeghem P, Carpentier N, Deliens L. Different trends in euthanasia acceptance across Europe. A study of 13 western and 10 central and eastern European countries, 1981-2008. Eur J Public Health. 2013;23(3):378–80. doi:.https://doi.org/10.1093/eurpub/cks186
  34. Cohen J, Marcoux I, Bilsen J, Deboosere P, van der Wal G, Deliens L. European public acceptance of euthanasia: socio-demographic and cultural factors associated with the acceptance of euthanasia in 33 European countries. Soc Sci Med. 2006;63(3):743–56. doi:.https://doi.org/10.1016/j.socscimed.2006.01.026
  35. Cohen J, Van Landeghem P, Carpentier N, Deliens L. Public acceptance of euthanasia in Europe: a survey study in 47 countries. Int J Public Health. 2014;59(1):143–56. doi:.https://doi.org/10.1007/s00038-013-0461-6
  36. Köneke V. Trust increases euthanasia acceptance: a multilevel analysis using the European Values Study. BMC Med Ethics. 2014;15(1):86. doi:.https://doi.org/10.1186/1472-6939-15-86
  37. Hendry M, Pasterfield D, Lewis R, Carter B, Hodgson D, Wilkinson C. Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliat Med. 2013;27(1):13–26. doi:.https://doi.org/10.1177/0269216312463623
  38. Rietjens JA, van der Heide A, Onwuteaka-Philipsen BD, van der Maas PJ, van der Wal G. A comparison of attitudes towards end-of-life decisions: survey among the Dutch general public and physicians. Soc Sci Med. 2005;61(8):1723–32. doi:.https://doi.org/10.1016/j.socscimed.2005.03.024
  39. Buiting HM, Deeg DJ, Knol DL, Ziegelmann JP, Pasman HR, Widdershoven GA, et al. Older peoples’ attitudes towards euthanasia and an end-of-life pill in The Netherlands: 2001-2009. J Med Ethics. 2012;38(5):267–73. doi:.https://doi.org/10.1136/medethics-2011-100066
  40. O’Neill C, Feenan D, Hughes C, McAlister DA. Physician and family assisted suicide: results from a study of public attitudes in Britain. Soc Sci Med. 2003;57(4):721–31. doi:.https://doi.org/10.1016/S0277-9536(02)00421-5
  41. Stolz E, Mayerl H, Gasser-Steiner P, Freidl W. Attitudes towards assisted suicide and euthanasia among care-dependent older adults (50+) in Austria: the role of socio-demographics, religiosity, physical illness, psychological distress, and social isolation. BMC Med Ethics. 2017;18(1):71. doi:.https://doi.org/10.1186/s12910-017-0233-6
  42. Stronegger WJ, Burkert NT, Grossschädl F, Freidl W. Factors associated with the rejection of active euthanasia: a survey among the general public in Austria. BMC Med Ethics. 2013;14(1):26. doi:.https://doi.org/10.1186/1472-6939-14-26
  43. Van Hiel A, Van Assche J, De Cremer D, Onraet E, Bostyn D, Haesevoets T, et al. Can education change the world? Education amplifies differences in liberalization values and innovation between developed and developing countries. PLoS One. 2018;13(6):e0199560. doi:.https://doi.org/10.1371/journal.pone.0199560
  44. Caddell DP, Newton RR. Euthanasia: American attitudes toward the physician’s role. Soc Sci Med. 1995;40(12):1671–81. doi:.https://doi.org/10.1016/0277-9536(94)00287-4
  45. Chambaere K, Rietjens JA, Cohen J, Pardon K, Deschepper R, Pasman HR, et al. Is educational attainment related to end-of-life decision-making? A large post-mortem survey in Belgium. BMC Public Health. 2013;13(1):1055. doi:.https://doi.org/10.1186/1471-2458-13-1055
  46. Vilpert S, Borrat-Besson C, Borasio GD, Maurer J. Associations of end-of-life preferences and trust in institutions with public support for assisted suicide evidence from nationally representative survey data of older adults in Switzerland. PLoS One. 2020;15(4):e0232109. doi:.https://doi.org/10.1371/journal.pone.0232109
  47. Poli S. Attitudes Toward Active Voluntary Euthanasia Among Community-Dwelling Older Subjects. SAGE Open. 2018;8(1). doi:.https://doi.org/10.1177/2158244017753868
  48. Scherrens AL, Roelands M, Van den Block L, Deforche B, Deliens L, Cohen J. What influences intentions to request physician-assisted euthanasia or continuous deep sedation? Death Stud. 2018;42(8):491–7. doi:.https://doi.org/10.1080/07481187.2017.1386734
  49. Leinbach RM. Euthanasia Attitudes of Older Persons - a Cohort Analysis. Res Aging. 1993;15(4):433–48. doi:.https://doi.org/10.1177/0164027593154004
  50. Braun KL, Tanji VM, Heck R. Support for physician-assisted suicide: exploring the impact of ethnicity and attitudes toward planning for death. Gerontologist. 2001;41(1):51–60. doi:.https://doi.org/10.1093/geront/41.1.51
  51. Reich O, Signorell A, Busato A. Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data. BMC Health Serv Res. 2013;13(1):116. doi:.https://doi.org/10.1186/1472-6963-13-116
  52. Hurst SA, Zellweger U, Bosshard G, Bopp M ; Swiss Medical End-of-Life Decisions Study Group. Medical end-of-life practices in Swiss cultural regions: a death certificate study. BMC Med. 2018;16(1):54. doi:.https://doi.org/10.1186/s12916-018-1043-5
  53. Panczak R, Luta X, Maessen M, Stuck AE, Berlin C, Schmidlin K, et al. Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data. Med Care. 2017;55(2):155–63. doi:.https://doi.org/10.1097/MLR.0000000000000634
  54. Cohen J, Van Wesemael Y, Smets T, Bilsen J, Deliens L. Cultural differences affecting euthanasia practice in Belgium: one law but different attitudes and practices in Flanders and Wallonia. Soc Sci Med. 2012;75(5):845–53. doi:.https://doi.org/10.1016/j.socscimed.2012.04.021
  55. Van den Block L, Deschepper R, Bilsen J, Bossuyt N, Van Casteren V, Deliens L. Euthanasia and other end-of-life decisions: a mortality follow-back study in Belgium. BMC Public Health. 2009;9(1):79. doi:.https://doi.org/10.1186/1471-2458-9-79
  56. Fischer S, Bosshard G, Faisst K, Tschopp A, Fischer J, Bär W, et al. Swiss doctors’ attitudes towards end-of-life decisions and their determinants: a comparison of three language regions. Swiss Med Wkly. 2006;136(23-24):370–6.
  57. Danyliv A, O’Neill C. Attitudes towards legalising physician provided euthanasia in Britain: the role of religion over time. Soc Sci Med. 2015;128:52–6. doi:.https://doi.org/10.1016/j.socscimed.2014.12.030
  58. Lapierre S, Castelli Dransart DA, St-Amant K, Dubuc G, Houle M, Lacerte MM, et al. Religiosity and the Wish of Older Adults for Physician-Assisted Suicide. Religions (Basel). 2018;9(3):66. doi:.https://doi.org/10.3390/rel9030066
  59. Pott M, Cavalli S, Stauffer L, Lou Beltrami S. Les membres âgés des ADMD: des personnes déterminées et un défi à relever pour les soignants. Angewandte Gérontologie Appliquée. 2018;3:23–6.
  60. Sheeran P, Webb TL. The Intention-Behavior Gap. Soc Personal Psychol Compass. 2016;10(9):503–18. doi:.https://doi.org/10.1111/spc3.12265
  61. Abrams D, Vauclair CM, Swift H. Predictors of attitudes to age across Europe. Research report no. 375. Sheffield: Department for Work and Pensions; 2011.
  62. Vilpert S, Borrat-Besson C, Maurer J, Borasio GD. Awareness, approval and completion of advance directives in older adults in Switzerland. Swiss Med Wkly. 2018;148:w14642. doi:.https://doi.org/10.4414/smw.2018.14642
  63. Vilpert S, Maurer J, Borasio GD. Knowledge gaps with regard to end-of-life care and planning options among older adults in Switzerland. Submitted manuscript. 2020.