Introduction

Modern Western societies—North America and many European countries—tend to refrain from discussion of death (Tradii & Robert, 2017). While some perceive death as cruel, unreasonable, and unpredictable, others may view it as a relief from unendurable pain. The ability to choose how and when to end one’s own life has evolved into the practices of euthanasia and assisted suicide (AS).

Assisted suicide has been legal in Switzerland since Article 115 of the Swiss penal code went into effect in 1942. Unlike other countries that have legalized various forms of assisted dying, Switzerland has more permissive regulations around assisted suicide. This characteristic is reflected in Switzerland’s cultural, legal, and ethical framework, which stresses the importance of self-determination, personal autonomy, and dignity. The only form of assisted dying punishable under the Swiss penal code is direct active euthanasia. Moreover, there are no regulations restricting who may assist with the dying process. This lack of specificity was intentional, allowing both medical and non-medical professionals maximum freedom to conduct the procedure. The loose regulations of the Swiss penal code have granted the public considerable freedom, but they have also sparked prolonged debates over how assisted suicide should be handled.

Following the implementation of Article 115, public perception has become increasingly accepting of assisted suicide over time, rising from 53 cases in 2005 to 504 cases in 2023, according to quantitative data from EXIT, the first right-to-die organization established in Switzerland (Bise, 2024). However, the path from 1942 to today has been far from easy. EXIT was established in 1982, but the first official assisted suicide case through EXIT did not take place until 1998. Physicians, family members, and other professionals involved in the process of assisted suicide have long battled stigmatization, public accusations, and opposition from palliative care and pro-life organizations. Public opposition has instigated self-doubt, as well as moral and ethical dilemmas, among those assisting with AS requests and has increased stress for those working in the field. Many research studies focus on legislative debates to advance assisted dying, push for euthanasia legalization, or impose more restrictions on existing practices. However, relatively few studies have explored the evolution of public attitudes toward assisted suicide in Switzerland over time, as well as the effects stemming from this shift.

This paper aims to provide an overview of how public attitudes and perceptions toward assisted suicide, as well as the relationship between palliative care and AS, have changed over time. The main research question of this paper is how changes in public attitudes toward assisted suicide affect families and professionals involved in the process of AS in Switzerland.

Research Methodology

This study relied on secondary data, including literature reviews, documentary sources, and secondary qualitative and quantitative data from interviews recorded in published journals, as well as primary data from interviews, transcripts, and notes taken during the interviews. The primary research question of this study required the use of qualitative data due to its focus on attitudes, emotions, and personal encounters as reported by professionals and relatives. However, quantitative data were also valued to illustrate the annual increase in assisted suicide requests within right-to-die associations as an indication of growing social acceptability.

Interview questions addressed: (1) the interviewee’s personal stance on AS, (2) the interviewee’s professional background and experience working with AS cases, and (3) anecdotal experiences handling difficult AS cases or mitigating conflicts between physicians, family members, patients, and AS volunteers with differing perspectives on AS.

Results

Factors that influence attitudes towards AS

Demographic, experience-related, and ideological factors may be predictive of attitudes toward AS (Worthen & Yeatts, 2001). Studies have found that physicians' experience, defined roughly by the number of contacts with terminally ill patients, may be related to their attitude toward AS. Studies by Bachman et al., 1996 and Cohen et al., 1994 observed that physicians who most frequently work with terminally ill patients tend to be the ones who are less supportive or even strongly oppose assisted dying, whereas physicians with the least exposure to terminally ill patients (psychiatrists) are the most supportive of AS (Ganzini et al., 1996). However, findings from these studies are not up-to-date, and some findings may no longer hold in today's context. Furthermore, initial findings from when the studies were first published are conflicting, making experience-related factors inconclusive (Worthen & Yeatts, 2001).

Figure 1.

Different concepts of MAiD. Based on the interview and information from the EXIT A.D.M.D. presentation. The Swiss Penal Code only deals with direct active euthanasia.

Upon analyzing age as a demographic factor in attitudes toward AS, past and contemporary studies have both shown the trend that younger respondents tend to be more supportive of AS compared to older respondents (Blendon et al., 1992; Mickiewicz et al., 2012). This trend has not changed much over time, making age a commonly recognized contributing factor. In addition, Leinbach (1993) found that individual attitudes did not vary significantly over time as participants aged.

Another factor studied was religiosity. Different religions and the depth of religious commitment could both influence attitudes toward assisted suicide. Most religious members, including Muslims, Christians, and Jews, hold a negative view toward assisted dying (Cayetano-Penman et al., 2021). Religiosity was negatively correlated with approval of AS, especially among Christian participants surveyed (Rajkumar, 2021; Chakraborty et al., 2017). Opposition stems from the belief that “[life and] moment of death belongs to God” (Parpa et al., 2010). According to a study by Spoerri et al. (2010) that investigated the correlation between religious affiliations and suicide, both assisted and non-assisted, the effect of religious affiliation seemed to shield more Catholics than Protestants, older individuals than younger ones, and more women than men from assisted suicides. The findings from this article also supported and matched conclusions about the demographic factors mentioned above. “Religion is difficult... and in the past, when we visited Cantons or villages that were more religious than others, we sometimes feared being rejected…but now, [the situation] is better…the Swiss society is becoming more secularized” (J-J. Bise, personal communication, April 11, 2024).

Discussion

The change in public attitude toward AS over time may not have been triggered by any specific event or policy. It may simply be because those “young respondents” from the past who favored AS grew to become authoritative representatives, experts, and professionals in the field today while still holding their favorable attitudes toward AS. Their opinions on AS continue to influence the younger population, facilitating the development of a more open environment for discussion of AS and more favorable views toward the practice of AS. The increase in secularization may also be due to generational effects, similar to the effects of age on public attitudes toward AS.

Physicians play an important role in the initial stages of AS, and their attitudes and values could have a great impact on the experience of patients and families throughout the process of assisted suicide. This suggests that proper training and guidance are essential for palliative care physicians. Some physicians may mistake their feelings of uncertainty and unfamiliarity as opposition to AS, turning down AS requests because they are unsure how to help or unaware of their own values. Institutional-level support could also help alleviate the uneasiness of palliative care physicians. The more professionals realize and identify with their own values, the better it is for themselves, their patients, and the experience of the families. To prevent negative emotions arising from a clash of personal values and professional missions from affecting the quality of care, clear and open communication early on is the best solution to avoid intentional or unintentional gatekeeping. When providers realize their own limitations in handling AS requests, they should take the initiative in referring the patient to a different person whose philosophy may align more with AS and who is willing to assist. More education and training in the future, both at the individual and institutional levels, could help physicians better understand their own stance and minimize emotional distress when dealing with requests for AS. Many professionals, about half of the respondents, wished to receive more reliable information and support on issues surrounding end-of-life care at the institutional level, whether it is palliative care, assisted suicide, or euthanasia (Castelli Dransart, D.A., Scozzari, E., & Voélin, S.. 2017).

With the trend of increasing support and acceptance of AS among the public and professionals, more palliative care medical professionals and nurses who used to take a critical and opposing stance against AS are slowly changing and evolving to adopt a neutral perspective on AS. As they become familiar with the act of AS through professional exchanges and interactions with right-to-die associations, medical professionals may become more motivated to learn about and be involved in the process of AS (Gamondi et al., 2022). Physicians’ attitudes and experiences with AS are highly valuable and have a significant influence on the public perspective on AS. Following the increasingly neutral stance and decreasing hostility toward assisted suicide, more people may adopt the philosophy of being personally disagreeing yet empathetically supportive and supportive. This means that they may never choose AS for themselves or still have unresolved value conflicts against the idea of AS, but they will understand and unconditionally support the choice of their loved ones if they choose AS.

The relationship between EXIT volunteers and families was discussed during the interview. In cases where there is a conflict between the patient requesting AS and their family members, EXIT volunteers remain neutral while attempting to mitigate the conflict and respect the autonomy of the person requesting AS. Typically, the illnesses of patients who meet EXIT’s criteria for AS exacerbate over time, and the suffering becomes increasingly intolerable. Family members slowly come to understand the patient’s decision, even if they are still against the concept of AS. In recent years, more families have begun to openly thank right-to-die associations such as EXIT for their contributions to freeing their loved ones from suffering. Once again, this change in behavior reflects the increasingly supportive attitude of the public toward AS. The change in public attitude will undoubtedly continue to influence future generations, helping normalize AS in the public mind. These small acts of kindness from family members will become new sources of motivation and signs of affirmation for volunteers assisting in the process of assisted suicide.

In the ongoing discussion on assisted suicide, the experiences of families sometimes go unrecognized, and clinical guidelines seldom take their perspectives into account. Family support is crucial throughout the process of AS. The Swiss model of assisted suicide especially requires families to invest much more time and effort than alternative models in other countries. Family members sometimes get caught up in the battles between palliative care and right-to-die associations. There are mixed feelings about families’ decisions regarding the disclosure of their experiences with AS. Part of the reason is personal, and another part is fear of negative judgments from others. This also ties into the evolving public attitude and stigmatization surrounding AS. Some families prefer secrecy and high confidentiality throughout the process of AS, minimizing the discussion of AS and their own emotional burdens with other families or professionals. While this may protect them from perceived judgments in the eyes of the public, it may also intensify the sense of isolation and exacerbate their grief during the bereavement period (Wagner et al., 2012; Gamondi et al., 2020). Nonetheless, other families value sharing their experiences and having clear and open communication around both AS and other end-of-life issues so that patients’ and families’ needs can be expressed and addressed in a timely manner. However, doing so may make families the target of opponents of AS and victims of stigmatization. Philippkowski et al. (2021) conducted research comparing public stigma toward those bereaved of AS with those bereaved of death from different causes. The stigma elicited did not differ significantly between AS and other deaths (e.g., long-term illness), suggesting no evidence of more severe stigma against assisted dying. The perceived public stigma may be unfounded or significantly reduced due to the evolving public attitude toward greater favorability of assisted dying. Sometimes, self-stigma due to perceived, though unproven, public stigma is the biggest barrier preventing families from seeking external support.

Families play a crucial role in dispelling fear and misunderstandings about AS in the public. Perceived stigma and negative public attitudes often originate from insufficient understanding and fear of the unknown. Thus, family members who have been through the entire process are the best candidates to educate the public about AS through their personal experiences. Physicians, guided by professional obligations, are fundamentally committed to preserving life, while right-to-die association volunteers, due to self-selection bias, are predisposed to support assisted suicide. In contrast, family members are relatively independent in their perspectives, as they are not bound by professional ethics or organizational ideologies, making them key in mitigating potential conflicts between physicians and volunteers. The changing societal perception of AS and public attitudes have a great impact on families’ experiences with AS. Conversely, family members who have been involved in AS are influential figures with the potential to shape the development of public attitudes toward AS in the future.

Conclusion

Data from both literature reviews and interviews support the fact that Swiss society is becoming more tolerant and supportive of assisted suicide. After a long history of conflict and debates, palliative care and AS have finally reached the point of mutual respect, marked by collaborative efforts across professional fields and growing social acceptance. Demographic, experience-related, and religious ideological factors may continue to influence people’s stances on AS, but religiosity is no longer as powerful as it was in the past.

Palliative care physicians’ attitudes toward AS are shifting toward greater neutrality, with decreased hostility and increased curiosity to understand and potentially be more involved in AS. Perhaps due to both the influence of changing public attitudes toward AS and generational effects, more palliative care physicians have approved the practice of AS within hospitals.

EXIT volunteers’ consistent and reliable support and families’ advocacy about their experiences with AS have also greatly contributed to shaping a positive image of assisted suicide in Switzerland. The public’s acceptance motivates volunteers from right-to-die associations to continue helping more families as the demand for AS increases annually.

Having public understanding encourages families to dispel potential self-stigma and have more open conversations in public regarding their personal experiences with AS. The influence of public attitude and the attitudes of families and professionals is reciprocal. The change in public attitude and perception toward assisted suicide has facilitated better experiences for family members and professionals involved in AS. Vice versa, the acknowledgment and support from families and professionals sway public perception to be more favorable toward AS in Switzerland.