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End of life
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Suicide tourism: a pilot study on the Swiss phenomenon
  1. Saskia Gauthier1,
  2. Julian Mausbach2,
  3. Thomas Reisch3,
  4. Christine Bartsch1
  1. 1Institute of Legal Medicine, University of Zurich, Zurich, Switzerland
  2. 2Centre for Medicine—Ethics—Swiss Law, Institute of Jurisprudence, University of Zurich, Zurich, Switzerland
  3. 3Psychiatric Clinic, Centre for Psychiatry, Münsingen, Switzerland
  1. Correspondence to Dr Saskia Gauthier, Institute of Legal Medicine, University of Zurich, Winterthurerstrasse 190, Zurich 8057, Switzerland; saskia.gauthier{at}irm.uzh.ch

Abstract

While assisted suicide (AS) is strictly restricted in many countries, it is not clearly regulated by law in Switzerland. This imbalance leads to an influx of people—‘suicide tourists’—coming to Switzerland, mainly to the Canton of Zurich, for the sole purpose of committing suicide. Political debate regarding ‘suicide tourism’ is taking place in many countries. Swiss medicolegal experts are confronted with these cases almost daily, which prompted our scientific investigation of the phenomenon. The present study has three aims: (1) to determine selected details about AS in the study group (age, gender and country of residence of the suicide tourists, the organisation involved, the ingested substance leading to death and any diseases that were the main reason for AS); (2) to find out the countries from which suicide tourists come and to review existing laws in the top three in order to test the hypothesis that suicide tourism leads to the amendment of existing regulations in foreign countries; and (3) to compare our results with those of earlier studies in Zurich. We did a retrospective data analysis of the Zurich Institute of Legal Medicine database on AS of non-Swiss residents in the last 5 years (2008–2012), and internet research for current legislation and political debate in the three foreign countries most concerned. We analysed 611 cases from 31 countries all over the world. Non-terminal conditions such as neurological and rheumatic diseases are increasing among suicide tourists. The unique phenomenon of suicide tourism in Switzerland may indeed result in the amendment or supplementary guidelines to existing regulations in foreign countries.

  • End-of-life
  • Suicide/Assisted Suicide
  • Forensic Medicine

https://doi.org/10.1136/medethics-2014-102091

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    Introduction

    In Switzerland, assisting suicide is not clearly regulated by law and unlike in other countries such as the Netherlands or certain states of the USA, for example, Oregon, no rules exist that regulate under which conditions someone might receive assisted suicide (AS). Instead, there are some laws that altogether rule AS: the 1942 penal code (Art. 115) states only that “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”.1 The medical professional code allows doctors to provide assistance in suicide in certain circumstances, when they assume that the end of life is near or the patient is in the end stage of a terminal illness.2 ,3 Sodium pentobarbital, the medication most commonly used for AS, can only be prescribed under specific conditions, according to the Swiss law on drugs.4 ,5 There are, therefore, some legal grey areas, and this is one of the reasons why the European Court of Human Rights recently ruled that Switzerland has to issue regulations for prescribing lethal medication such as sodium pentobarbital.6 Several attempts to regulate AS by federal law from the 1990s until the present day have failed, most recently in June 2011, when the Bundesrat (Federal Council) decided that there was no need to change the law, because no advantages, but disadvantages were to be expected after amendments of Art. 115 and that the current wording of Art. 115 was enough to detect a possible misuse7 ,8

    At a cantonal level, there have been various attempts to regulate AS by law—each case of AS results in legal investigation, which costs approximately 3000 Swiss Francs, carried by the canton of Zurich and independent of the fees paid directly to the organisation by the member. A draft bill, restricting AS to people who had lived in the Canton of Zurich for at least 1 year, was rejected by the population of the canton in May 2011; another draft bill to regulate and supervise the right-to-die organisations was rejected by the cantonal government in July 2013.9 ,10 Six official voluntary right-to-die organisations are active in Switzerland and offer AS to their members, providing that they fulfil various conditions. These conditions differ between the organisations, as can be seen in table 1.11–24 Four of the six organisations also offer suicide assistance to people who are neither Swiss citizens nor resident in Switzerland, but who come from other European countries, for example, the UK, France and Italy, where AS is restricted by law and anyone contravening this law may be liable to several years’ imprisonment.16–30 The imbalance between there being no definitive legislation in Switzerland and the clearly restrictive regulations in other European countries results in an influx of people who come to Switzerland for the sole purpose of committing suicide aided by one of these organisations. Such people are referred to as suicide tourists, a phenomenon unique to Switzerland. In the UK, at least, ‘going to Switzerland’ has become a euphemism for AS. According to their own websites, the six right-to-die organisations assist in approximately 600 cases of suicide per year; some 150–200 of which are suicide tourists, mostly with Dignitas, in the canton of Zurich.11–24 As medicolegal experts at the Institute of Legal Medicine in Zurich, we are called on almost every day to examine cases of suicide tourism, and this prompted us to carry out the pilot study.

    View this table:
    Table 1

    Right-to-die organisations in Switzerland

    The study examines suicide tourism in the Canton of Zurich between 2008 and 2012. Our hypothesis was that the phenomenon of suicide tourism in Switzerland leads to the amendment of existing laws in foreign countries because of the political debate it stimulates. The study had three aims:

    1. To determine selected details about AS:

      • age and gender of the suicide tourists

      • organisation involved

      • ingested substance leading to death

      • the diseases most frequently given as the reason for AS

    2. To find out the countries from which the suicide tourists come and to review legislation in the three main countries concerned, with a view to testing the hypothesis that suicide tourism leads to the amendment of existing laws in foreign countries.

    3. To compare our results with those of earlier studies in the Canton of Zurich and to discuss possible differences and developments.

    Methods

    In this pilot study, we searched the databases of the investigations and postmortem examinations carried out by the Institute of Legal Medicine in Zurich, the Canton most often concerned. The Institute of Legal Medicine is responsible for the city of Zurich and for cases of Dignitas performed in Pfäffikon, a small village within the canton of Zurich. The search terms were ‘assisted suicide’, the names of the different right-to-die organisations such as ‘dignitas’ or ‘exit’ or ‘spirit’ or ‘lifecircle’, or ‘NAP’ (German abbreviation for sodium pentobarbital), ‘foreigners’ and ‘suicide tourism’. We included all foreign residents who had been given assistance in suicide during the period 1 January 2008–31 December 2012. The cases identified were screened for gender, age, date of birth, date of death, country of residence and main diseases. This study included only information found using the Lotus Notes 8.5 computer program of the Institute of Legal Medicine in Zurich. All files will be studied using a standardised questionnaire as part of the ongoing research project.

    A frequency analysis was done with Excel 2010.

    We searched the internet for the existing legislation in the three countries from which most of the suicide tourists came. We followed the political debate and looked at any possible amendment of the existing laws. PubMed and MEDLINE were searched for existing scientific publications and political debates on suicide tourism.

    Results

    Selected details of AS in the study group

    Of the 611 cases included in the study, 58.5% were women (annual range 54–62%). The age ranged from 23 to 97 years, with a median of 69. Table 2 shows that, after an initial decrease between 2008 and 2009, cases of suicide tourism identified in the Canton of Zurich increased from then onwards and doubled in number by 2012. Dignitas was the right-to-die organisation involved in nearly all cases; Exit was involved in only four. We did not find any cases involving other organisations or cases independent of an organisation. Ingestion of sodium pentobarbital led to death in all but four cases when inhaled helium was used to commit suicide in the spring of 2008. The underlying diseases varied considerably; table 3 shows that the main reasons were neurological disease (47%), followed by cancer (37%), rheumatic and cardiovascular disease. Approximately one-third (28%) of the study group gave more than one disease as the reason for AS.

    View this table:
    Table 2

    All cases per year and country

    View this table:
    Table 3

    Diseases given as reason for AS

    Where the suicide tourists came from, and the legislation on AS in the top three countries

    Altogether, 611 cases during the study period 2008–2012 met the inclusion criteria. Table 2 shows that, although suicide tourists came from 31 different countries worldwide, most were from Europe. Nearly half came from Germany (43.9%), followed by the UK (20.6%) and France (10.8%). Over the years more countries were concerned but suicide tourism from Germany, Italy, France, the UK and the USA increased the most. Italy in particular had 10 times as many suicide tourists in 2012 as it did in 2008. Reviewing the laws in the top three countries, we found that AS is not clearly regulated in Germany. It is, however, strictly restricted in the UK and France, where existing laws have been extended in recent years.

    Germany

    Explicit legislation on assisted dying does not yet exist in the German criminal code.31 According to the Federal Medical Association’s professional code of conduct, doctors are forbidden to help someone to commit suicide.32 Furthermore, under §323c of the German criminal code, it may be considered that a change of authority takes place as soon as the person committing suicide becomes unconscious. This might lead to doctors who witness a suicide and do not start resuscitation procedures being criminally liable—an ethical dilemma.31 In Germany, some physicians consider their ethical values higher than the law and still do help people commit suicide.24 However, the Federal Medical Association does not judge ethical values higher than the current law. Nevertheless, efforts have recently been made to establish a legal framework for AS in Germany. A draft law, intended to create a new section in the criminal code, was published by the Ministry of Justice on 22 October 2012. This section—§217 E of the German criminal code—was supposed to penalise commercial organisations repeatedly offering assistance in suicide for gain, including annual membership fees. Advertising or giving specific information in Germany for facilitating AS abroad would also be forbidden. Relatives, friends and physicians offering assistance for compassionate reasons would remain free from prosecution.33 An international survey among the populations of 12 countries in autumn 2012 showed that 76% of the German population rejected the draft bill.34 After this first step of the legislative process, the draft bill effectively had no chance in the political discussion and failed. At present, it seems unlikely that this draft bill will be adopted into law in the foreseeable future.

    The UK and Ireland

    According to section 2 (1) of the Suicide Act from 1961, assisting suicide in England and Wales is punishable by up to 14 years in prison.25 ,26 ,27 ,28 This includes people who have accompanied loved ones to Switzerland in order to facilitate their AS. According to the Home Office Statistical Bulletin, 141 persons were registered by the police for assisting suicide between 1997 and 2011/2012, although the precise aid is not specified.35 ,36 In February 2010, the Director of Public Prosecutions (DPP) introduced new policy guidelines on prosecuting suicide assistance, following legal action for clarification brought by Debbie Purdy.37–40 Ms Purdy was diagnosed with multiple sclerosis in 1994 and wanted to know whether her husband would remain free from prosecution if he accompanied her to Switzerland to facilitate her AS.39 ,41 After the decision by the House of Lords, the DPP had to issue new guidelines. The current policy allows assisting someone to commit suicide may be free from prosecution in certain circumstances, for example, when the decision to commit suicide was voluntary, clear, settled and informed. In addition, the person assisting had to be acting out of compassion.38 Until recently, there had been no prosecutions for the offence since the introduction of the 2010 policy, but in August 2013 the wife and son of a man who wanted to commit suicide in Switzerland with the help of Dignitas were arrested.42 The impact of this case on the current guidelines remains to be seen. Organisations such as Dignitas and Exit are still forbidden by law.43 Draft bills intending to liberalise AS were rejected in 2006 and 2009. Nevertheless, another draft bill, proposed by Lord Falconer, is in the legislative process. One of its key points is that certain conditions (eg, terminal illness, mental competence and a wish to die confirmed by two doctors) have to be met before someone receives assistance in dying, such as permission to receive a lethal drug. Lord Falconer's assisted suicide bill is currently (9 January 2013) awaiting its second reading (debate stage) in the House of Lords.44

    Scotland has no regulations or case law on AS. Depending on the specific circumstances, a person might be criminally liable for homicide if they have helped someone to commit suicide. Margo MacDonald has launched a bill to liberalise AS.27 According to Peter Warren, office manager and researcher at the Scottish Parliament, this bill will be debated by the Scottish Parliament in 2014.

    In Northern Ireland, aiding suicide is a criminal offence according to section 13 of the 1966 Criminal Justice Act and punishable by up to 14 years’ imprisonment.26 In 2010, the Public Prosecution Service for Northern Ireland issued guidelines similar to those in England and Wales.45

    In Ireland, according to the Criminal Law, the Suicide Act from 1993 2 (2) aiding someone's suicide is a criminal offence with up to 14 years’ prison.28 Actually a woman diagnosed with multiple sclerosis (MS) argued for the right to facilitate AS and for guidelines comparable to those from the DPP in the UK. Her arguments were appalled by the High Court and are now to be determined by the Supreme Court.39

    France

    In France, according to Article 223, 13–15 of the penal code, inciting a person to commit suicide is punishable with up to 3 years’ imprisonment, or even 5 years if the intended suicide was younger than 15 years of age.29 Furthermore, two special features of French law have to be mentioned. First, similar to German law, it is considered that a change of authority takes place as soon as the person committing suicide becomes unconscious. In France as well, this might lead to the criminal liability of people who witness a suicide and do not start resuscitation procedures. Second, promoting suicide methods is forbidden by law.

    A legislative process on an end-of-life law is currently underway in France.46 The draft bill intends to liberalise physician-assisted suicide and to allow medically assisted suicide for terminally ill patients. It stipulates that a medical team can assist in ending a patient's life in certain circumstances.47–49

    An international survey of the populations in 12 European countries, including Germany, the UK and France, revealed that the majority of the people interviewed were in favour of legalising AS in all of the countries surveyed.34

    Earlier studies

    Two earlier studies examined AS in the Canton of Zurich. Only one of them included suicide tourists, although without any in-depth analysis or determining any differences from Swiss residents who committed suicide.50 ,51 As table 4 shows, not only the number of suicide tourists has increased since 2001, but also the absolute number of cases of AS in the Canton of Zurich between 2009 and 2012. In comparison with the findings of Fischer et al, there was a large increase in people coming from the UK, more people coming from France and slightly fewer coming from Germany. The number of countries involved has also increased since then. Their results showed that only 12.4% of the 255 suicide tourists came from a few countries other than the top three, while in our study 25% came from elsewhere, with numbers increasing from year to year to include another 28 countries worldwide.51 Table 4 also shows that we found neurological and rheumatic diseases to be more common among suicide tourists in Zurich than in the study groups of Bosshard and Fischer.50 ,51

    View this table:
    Table 4

    Comparison with earlier studies on AS in the Canton of Zurich

    Discussion

    The present descriptive pilot study presents selected results from an ongoing research project on AS in Switzerland during the past 30 years. Our results show that not only AS but also suicide tourism has increased since 1990 and the first report with data in 2001. Regarding the selected details of suicide tourism, our results show that AS is chosen 1.4 times more often by women, a figure that is reflected in the official statistics and the two studies by Bosshard and Fischer, which showed percentages of 54.4% and 64.2%, respectively.50 ,51 The official Federal Statistics Office (FSO) figures for Switzerland show, however, that suicide in general is committed approximately 2.5 times more often by men.52

    The median age of the suicide tourists in our study was 69 years, an age at high risk of malignancy or chronic disease, and similar to the average age for AS resp. euthanasia found in studies from Switzerland, the USA and Belgium.50 ,53–58

    After a decrease between 2008 and 2009, the number of suicide tourists doubled between 2009 and 2012. The initial fall could be explained by negative media reporting on the four cases of AS with helium inhalation in spring 2008.59 ,60 The deaths were described as excruciating. A detailed scientific description of video sequences of the events reported one case in which death occurred after more than 40 minutes’ inhalation of helium by mask, during which time the unconscious person moaned and had episodes of eyeball movement.61

    With respect to the underlying diseases, our results showed that neurological diseases were the reason for AS in nearly half of the study group. Table 4 shows that neurological diseases and rheumatic diseases increased between 1990 and 2012, while cancer became less common. These results imply that non-fatal diseases or diseases that are not yet end stage (ie, not meeting the criteria required for Swiss doctors) are more often becoming the reason for seeking AS. Our results should be interpreted carefully, however, because approximately one-third of our study group had more than one disease, while it is not clear from the earlier studies by Bosshard and Fischer whether only one disease was mentioned for each person. In addition, we examined only suicide tourists, while the other two studies included either Swiss residents alone or residents and suicide tourists.50 ,51 It is possible that suicide tourists suffer from such diseases more often than Swiss residents or that those with terminal cancer are not able to travel to a foreign country. The ongoing AS research project will show whether suicide tourists suffer more often from non-end-stage disease than Swiss residents or if non-terminal disease is increasing in all cases of AS in Switzerland.

    The study found not only a clear increase in absolute numbers of suicide tourists but also in the countries from which they came. Looking at the legislation in the top three countries, political debate is to be found in all three. Our hypothesis that suicide tourism can result in the amendment of existing laws is confirmed by the examples of the UK and Germany. In the UK, the phenomenon of suicide tourism caused Debbie Purdy to bring about legal action to clarify the position regarding the prosecution of persons assisting in suicide. This case impacted jurisdiction with supplementary guidelines to the existing law in 2010, resulting in an overall liberalisation of the prosecution practice in the UK following assistance in suicide.39 ,62 Our results indicate a further increase in the flow of suicide tourists from the UK since the issue of these guidelines. This needs to be looked at in more depth, but it seems a possible interpretation at the present time. The increasing numbers of ‘suicide tourists’ from Germany into Switzerland and assisted dying also taking place in Germany gave rise to a draft law at the end of 2012, in which commercial suicide assistance would be punishable. As this draft is currently suspended, we have to await any further developments.33 Should the law be passed, however, the branch in the north German city of Hannover that Dignitas has maintained since 2005 would basically be at risk because of its advertising activities. A direct impact of this draft law on Switzerland can be seen in the newly founded right-to-die organisation SterbeHilfeDeutschland e.V., a satellite of the association with the same name founded in Hamburg in 2009. The founder in both cases is Roger Kusch, a former justice minister in Hamburg. He told the media that he wanted to establish his organisation on legally firm ground: should suicide assistance in Germany became prohibited, he would then be forced to offer his German members suicide assistance in Switzerland.63 ,64 We have not found any direct effects of suicide tourism on the legislation in France in recent years. Even so, there have been drives to liberalise AS following the change of government.47–49 It remains to be seen whether the number of French suicide tourists will change after a possible liberalisation, and this will be discussed after completion of the ongoing research project.

    The number of suicide tourists from Italy increased tenfold over our study period. We can only speculate on the reasons for this upsurge: one possibility is that the death of Eluana Englaro in 2009 and the preceding political debate on life-sustaining measures made it clear to many Italians that liberalisation of AS was not at all likely in their country in the foreseeable future.65

    Conclusions

    The phenomenon of suicide tourism has been growing over the years and is still increasing unabated. Compared with the two earlier studies, our results showed an increasing proportion of neurological and rheumatic diseases diagnosed among the suicide tourists. This implies that non-fatal diseases are increasing among suicide tourists and probably also among Swiss residents, although potential suicide tourists with a terminal illness might not be able to travel to a foreign country. We intend to investigate this aspect further. On the whole, we found no differences in age and gender between the suicide tourists in our study and the cases of AS in earlier studies from the Canton of Zurich or from other countries where AS is legalised.

    The phenomenon of suicide tourism unique to Switzerland can indeed result in amendment or supplementary guidelines to existing regulations in foreign countries, as shown by our examples of the top three countries from which suicide tourists travelled. Political debate in Switzerland and other countries is continuing, with the possibility of further amendments in the near future, in both Switzerland and elsewhere, unless Switzerland issues clear and structured regulations on suicide tourism. The ongoing project Assisted suicide in Switzerland—Development over the last 30 years will furnish an in-depth analysis of AS in Switzerland in general and may provide a scientific basis for a generalised procedure in Switzerland, including suicide tourism.

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    Supplementary materials

    Footnotes

    • Transparency declaration The lead author affirms that the manuscript is an honest, accurate and transparent account of the study being reported; no important aspects of the study have been omitted; no discrepancies from the study as planned exist.

    • Acknowledgements The authors would like to thank Dr Meryl Clarke for linguistic improvement and critical comments and Dr Stephan Bolliger for structural help with the text. We are grateful to Margo MacDonald and Peter Warren for giving us information about the current situation of their proposed bill. Our thanks also to Philip Satherley for information about a proposed bill in England.

    • Contributors All authors had full access to all of the data and can take responsibility for the integrity of the data and the accuracy of the data analysis.

    • Funding The pilot study is part of the Assisted Suicide in Switzerland—Development over the last 30 years study (NFP67), which is funded by the Swiss National Science Foundation (grant no: 139240). The work of all authors was independent of the funding body.

    • Competing interests All authors have completed the Unified Competing Interest form and declare that JM, TR, CB and SG have no financial interests that may be relevant to the work submitted.

    • Ethics approval As part of the Swiss National Science Foundation project, Assisted Suicide in Switzerland –Development over the last 30 years, the pilot study was approved by the Eidgenössische Expertenkommission für das Berufsgeheimnis in der medizinischen Forschung (Federal expert committee for professional confidentiality in medical research).

    • Provenance and peer review Not commissioned; externally peer reviewed.

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