Practical Issues of Medical Experts in Assessing Persons With Mental Illness Asking for Assisted Dying in Switzerland

Probably not a substantial claim: may not pass S3 (load-bearing).

A survey of German-speaking psychiatrists in Switzerland reported that the majority of respondents would not support a request for assisted suicide in cases of severe mental disorder.

“A survey of German-speaking psychiatrists in Switzerland reported that the majority of respondents would not support a request for assisted suicide in cases of severe mental disorder (10).”

• cites [10] Hodel, 2019, Attitudes toward assisted suicide requests in the context of severe and persistent mental illness: a survey of psychiatrists in Switzerland, Palliat Support Care. sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In Switzerland, about 1,000 assisted suicides of Swiss citizens are carried out per year, with about 65,000 deaths per year.

“With about 65,000 deaths per year in Switzerland, about 1,000 assisted suicides of Swiss citizens are carried out with the help of assisted dying organizations per year.”

• Also stated in: § Ethical and Medico-Legal Guidelines · plain

  “According to figures from the assisted dying organization Exit 2018, around 1.5% of all deaths of Swiss citizens involve assisted suicide by an assisted dying organization. With about 65,000 deaths per year, this means about 1,000 assisted suicides of Swiss citizens by all assisted dying organizations per year.”

May combine two claims.

A representative national survey in May 2010 of around 1,500 Swiss people showed a liberal attitude toward assisted suicide in general, but a more skeptical attitude toward extending assisted dying to people with severe mental disorders and to older, 'tired of life' people without physical complaints.

“Also a representative national survey in May 2010 of around 1,500 Swiss people on their attitudes toward assisted suicide showed a liberal attitude in general, but a more skeptical attitude toward extending assisted dying to people with severe mental disorders and to older, “tired of life” people without physical complaints (9).”

• cites [9] Schwarzenegger, 2010, Was die Schweizer Bevölkerung von Sterbehilfe und Suizidbeihilfe hält: erste Resultate einer repräsentativen nationalen Befragung, JusletterNot checked yet

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Classified as probably not a substantial claim.

There is no statement to be found after which time period an end-of-life-wish is to be considered 'permanent,' especially regarding mental illnesses.

“There is, e.g., no statement to be found after which time period an end-of-life-wish is to be considered “permanent,” especially regarding mental illnesses.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In 2014, for every 7 cases of suicide, there were 5 cases of assisted suicide in Switzerland.

“In 2014, for every 7 cases of suicide, there were 5 cases of assisted suicide” (8).”

• cites [8] StatistikB Todesursachenstatistik 2014 Assisterter Suizid (Sterbehilfe) und Suizid in der Schweiz.2014Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

As a trend for 2016, the numbers of cases of assisted suicide almost match those of conventional suicide.

“Other literature state as a trend for 2016 that the numbers of cases of assisted suicide now almost match those of conventional suicide (6).”

• cites [6] Bartsch, 2019, Assisted suicide in Switzerland: an analysis of death records from swiss institutes of forensic medicine, Dtsch Arztebl Int. sourceNot checked yet

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May combine two claims.

The majority of the FMH rejected the inclusion of the revised SAMS guidelines into the Code of Professional Conduct, and the former version of 2004 is still valid under the FMH perspective.

“As a consequence, the majority of the FMH rejected the inclusion of the revised guidelines into the Code of Professional Conduct and the former version of 2004 is still valid under the FMH perspective.”

May combine two claims.

The SAMS Medical-ethical guidelines of 2004 are still valid for professional law and declare that the end-of-life-wish is well weighed and permanent, including the evaluation of therapeutic possibilities against the background of personal experiences and value convictions.

“The SAMS Medical-ethical guidelines of 2004 are still valid for professional law and declares that the end-of-life-wish is well weighed and permanent, including the evaluation of these therapeutic possibilities against the background of their personal experiences and value convictions (17).”

• cites [17] Bosshard, 2005, Urteilsfähigkeit von Menschen mit psychischen Störungen und Suizidbeihilfe, Schweizerische Juristen-Zeitung.Not checked yet

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May combine two claims.

In 2018, SAMS put revised guidelines into force, which are in discrepancy with current FMH rules.

“In 2018, the Swiss Academy of Medical Sciences (SAMS) put revised guidelines into force, which are in discrepancy to the current rules of the Swiss Medical Association (FMH).”

• Also stated in: § Ethical and Medico-Legal Guidelines · plain

  “Although, the SAMS put the revised 2018 guidelines into force which leads to a discrepancy between the FMH-rules and the SAMS-rules.”

• cites [14] 2018, Richtlinien: Umgang mit Sterben und TodNot checked yet

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May combine two claims.

Many mental disorders are characterized by variable courses and may be influenced to a substantial degree by social conditions.

“This argumentation can be followed as many mental disorders are characterized by variable courses and may be influenced to a substantial degree by social conditions (17).”

• cites [17] Bosshard, 2005, Urteilsfähigkeit von Menschen mit psychischen Störungen und Suizidbeihilfe, Schweizerische Juristen-Zeitung.Not checked yet

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Classified as probably not a substantial claim.

The Federal Supreme Court distinguished between the desire to die due to a treatable mental disorder, which calls for treatment, and the desire to die based on a self-determined, well-reflected and durable decision of a person capable of judgment.

“However, it needs to be distinguished between the desire to die due to a treatable mental disorder, which calls for treatment, and the desire to die based on a self-determined, well-reflected and durable decision of a person capable of judgment.”

• cites BGE 133 I 58 ff.Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The use of involuntary methods varies across Europe and obtaining clinical data about it is difficult.

“Literature suggests that the use of involuntary methods varies across Europe and to obtain clinical data about it is difficult (12).”

• cites [12] Jacobsen, 2012, Involuntary treatment in Europe: different countries, different practices, Curr Opin Psychiatry. sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Assisted suicide of mentally ill persons should only be possible with the utmost restraint and supported by a professional opinion.

“Furthermore, assisted suicide of mentally ill persons should only be possible with the utmost restraint and supported by a professional opinion (BGE 133 I 58 ff.).”

• cites BGE 133 I 58 ff.Not checked yet

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Classified as probably not a substantial claim.

As long as there are no legally binding guidelines, each expert must form his or her professional opinion according to his or her best professional knowledge and conscience, free of any guidelines.

“As long as there are no legally binding guidelines, each expert must form his or her professional opinion according to his or her best professional knowledge and conscience, free of any guidelines.”

Classified as probably not a substantial claim.

If the wish to die is based on an autonomous decision taking into account the overall situation determined by an in-depth expert psychiatric opinion, assisted suicide may be granted to mentally ill persons under certain circumstances.

“If the wish to die bases on an autonomous decision which takes into account the overall situation which is to be determined by an in-depth expert (psychiatric) opinion, assisted suicide may also be granted to mentally ill persons under certain circumstances (7).”

• cites [7] Häring, 2017, Fünf Mythen über Suizidhilfeorganisationen Jusletter, 8 MaiNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

If funding is not secured, the complex assessment of prerequisites through multi-professional teams or just one assessor cannot be sustained.

“Lastly, reliable funding should be secured, as it is otherwise to be expected that the complex assessment of prerequisites through multi-professional-teams or just one assessor cannot be sustained.”

• Also stated in: § Conclusions · hedged

  “If funding is not secured, it is to be expected that the complex assessment of prerequisites through multi-professional-teams or just one assessor cannot be sustained.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In palliative care medicine, the vaguely defined role of the patient was partly held responsible for the considerably varying guidelines on how to determine 'intolerable suffering' for the application of sedation therapy.

“In palliative care medicine, the vaguely defined role of the patient was partly held responsible for the considerably varying guidelines how to determine “intolerable suffering” for the application of sedation therapy (18).”

• cites [18] Schildmann, 2014, Palliative sedation therapy: a systematic literature review and critical appraisal of available guidance on indication and decision making, J Palliat Med. sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Assisted suicide in Switzerland is legal if carried out without selfish motives and there is a free will decision by a person with capacity of judgement and to act independently.

“Assisted suicide, which is carried out without selfish motives on the side of the helping person, only remains unpunished if there is a free will decision by the person willing to die who has the capacity of judgement and to act independently.”

• Also stated in: § Ethical and Medico-Legal Guidelines · plain

  “Assisted suicide, which is carried out without selfish motives on the side of the helping person, is legal if there is a free will decision by the person willing to die who has capacity of judgement and to act independently.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The association of a more frequent involuntary aspect in psychiatric treatments and a higher perceived stigma of psychiatric diseases might help to explain the difference in regarding the possibility of assisted dying in mental and somatic disorders in the public.

“The association of a more frequent involuntary aspect in psychiatric treatments and a higher perceived stigma of psychiatric diseases (13) might help to explain the difference in regarding the possibility of assisted dying in mental and somatic disorders in the public.”

• cites [13] Looper, 2004, Perceived stigma in functional somatic syndromes and comparable medical conditions, J Psychosom Res. sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

Assisted dying is a relevant social phenomenon.

“Accordingly, it can be assumed, that assisted dying is a relevant social phenomenon.”

Classified as probably not a substantial claim.

There is a tension between the psychiatrically sometimes necessary compulsory treatment and the right of self-determination of mentally ill persons.

“Thus, there is a tension between the psychiatrically sometimes necessary compulsory treatment and the right of self-determination of mentally ill persons.”

Probably not a substantial claim: may not pass S2 (checkable).

The severity of subjective suffering can only be approached by describing the practical life impact of the mental illness and the cognitive and emotional reaction of the assessed person.

“Whilst this produces an approximation of the seriousness of functional limitations, the severity of subjective suffering can only be approached by describing the practical life impact of the mental illness and the cognitive and emotional reaction of the assessed person thereof.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The assessment of the capacity of judgement by expert assessors is a standard procedure which normally includes in Switzerland the evaluation of cognition, valuation capability, formation of will and willpower.

“The assessment of the capacity of judgement by expert assessors is a standard procedure which normally includes in Switzerland the evaluation of cognition, valuation capability, formation of will and willpower (16).”

• cites [16] 2019Not checked yet

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Classified as probably not a substantial claim.

The Federal Supreme Court's judgement defined as requirements for assisted suicide the personal examination and assessment of capacity of judgment by the physician, an informative interview, a correct diagnosis and indication.

“As part of the regulation of assisted suicide the Federal Supreme Court's judgement defined as requirements the personal examination and assessment of capacity of judgment by the physician, an informative interview, a correct diagnosis and indication.”

• cites BGE 133 I 58 ff.Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

In these palliative care guidelines, psychological and existential suffering were designated as possible indications, associated with a clear lack of precise definitions of the respective terms.

“As possible indications in these guidelines were designated psychological and existential suffering associated with a clear lack of precise definitions of the respective terms (18).”

• cites [18] Schildmann, 2014, Palliative sedation therapy: a systematic literature review and critical appraisal of available guidance on indication and decision making, J Palliat Med. sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

In case of impaired judgement in relation to the mental disorder, there are high hurdles for compulsory treatments of mentally ill persons.

“Also, in case of impaired judgement in relation to the mental disorder there are high hurdles for compulsory treatments of mentally ill persons.”

May combine two claims.

Only the first two prerequisites (capacity of judgement and autonomous will) have a legal basis; the other two (severe suffering and consideration of alternatives) are not found in the law and are non-binding requirements issued by a private organization.

“However, it is important to highlight that only the first two prerequisites have a legal basis (capacity of judgement and autonomous will); the other two (severe suffering and consideration of alternatives) are not found in the law or the relevant regulations; they are from a mere legal perspective non-binding requirements, issued by a private organization.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Multidisciplinary assessments would help avoid biases and blind spots of mono-disciplinary assessments.

“Multidisciplinary assessments would help to avoid biases and blind spots of a mono-disciplinary assessments.”

• Also stated in: § Practical Implications · hedged

  “Also the multidisciplinary proceeding would help to avoid biases and blind spots of a mono-disciplinary assessment.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Vandenberghe proposed a long and elaborate exploration and evaluation process in psychiatric illness, including in cases of non-terminal illness, and a committee-based multidisciplinary evaluation before assisted suicide.

“Vandenberghe (20) proposed in this line a long and elaborate exploration and evaluation process in psychiatric illness, including in cases of non-terminal illness, a committee-based multidisciplinary evaluation before assisted suicide.”

• cites [20] Vandenberghe, 2018, Physician-assisted suicide and psychiatric illness, New Engl J Med. sourceNot checked yet

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Classified as probably not a substantial claim.

The assessment of 'severe suffering' contains room for interpretation when there are no points of reference using algorithms or statistical tools.

“Also the assessment of “severe suffering” on contains room for interpretation when there are no points of reference using algorithms or statistical tools.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

As social conditions change, the end-of-life-wish may change as well-or endure.

“As social conditions change, the end-of-life-wish may change as well—or endure.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

The wish of assisted suicide has become a social reality for a substantial proportion of the population, including-to a certain extent-persons with a mental illness.

“The wish of assisted suicide has become a social reality for a substantial proportion of the population, including—to a certain extend—persons with a mental illness.”

Classified as probably not a substantial claim.

In case of doubt, it must be assumed that the person has capacity of judgement.

“In case of doubt, it must therefore be assumed that the person has capacity of judgement.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Persons with mental illness asking for assisted suicide could be unable to finance an assessment lege artis and would therefore be deprived of the possibility granted to more financially backed peers or would have to resort to assessors without the above mentioned claims to standards.

“Persons with mental illness asking for assisted suicide on the other hand could be unable to finance an assessment lege artis and would thereof be deprived of the possibility granted to more financially backed peers or would have to resort to assessors without the above mentioned claims to standards.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The expert's financial motives only become selfish if professionals claim earnings significantly above the scope of the market norm, without any specific reason to do so.

“The expert's financial motives only then become selfish, if professionals claim earnings significantly above the scope of the market norm, without any specific reason to do so.”

• cites [7] Häring, 2017, Fünf Mythen über Suizidhilfeorganisationen Jusletter, 8 MaiNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

If compensation is based on the expert's administrative costs and expenses or if customary professional wages or fees are demanded, this is not to be considered as selfish motives within the meaning of art. 115.

“From a legal point of view it was stated, that if the compensation is based on the expert's administrative costs and expenses or if customary professional wages or fees are demanded, this is not to be considered as selfish motives within the meaning of art. 115 (7).”

• cites [7] Häring, 2017, Fünf Mythen über Suizidhilfeorganisationen Jusletter, 8 MaiNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

A multidisciplinary proceeding would help reduce personal beliefs and motivations for action.

“This procedure would help reduce personal beliefs and motivations for action.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Multi-person assessments would minimize the possibility of simplifying irrevocable decisions about life and death and the consequences thereof.

“The multi-person assessments would also minimize the possibility of simplifying irrevocable decisions about life and death and the consequences thereof.”