Examination of Witnesses (Questions 2400
- 2419)
THURSDAY 3 FEBRUARY 2005
DR KLAUS
HOTZ, DR
GIANCARLO ZUCCO,
PROFESSOR CHRISTIAN
SCHWARZENEGGER and MS
SARAH J SUMMERS
LLB, EXIT
Q2400 Chairman: The people you deal
with are residents of Switzerland?
Dr Zucco: They
are residents. It does not matter if they are foreigners or Swiss.
Q2401 Chairman: Could you give us
a short rundown on the nature of the organisation and what the
system is?
Dr Hotz: EXIT is
an association according to Swiss law. That is the easiest form
to organise in Switzerland, an association, which you know also
in England. EXIT has about 50,000 members, so it is a relatively
large association. A board is elected from the General Assembly
each year and the board has now five persons. These five persons
are leading EXIT. Then we have two additional organisations. We
have the Ethical Commission where two people are members which
decides difficult cases. Then we have the Compliance Commission
which is controlling what has been done and I am a member of the
Compliance Commission.
Q2402 Chairman: That is to see that
what is being done is complying with the rules?
Dr Hotz: The rules
within the association.
Q2403 Chairman: We have had described
to us the general law and particularly Article 115 of the Swiss
Penal Code and the earlier Articles which have a bearing on this,
so we have that kind of criminal law background already. In EXIT
I gather you have regulations that you have made in the association
yourselves for the way in which you carry out your activities.
Dr Hotz: We have
our statutes which are much stronger and where the conditions
for assisted suicide are much higher than the penal law, which
is of course very open. We must firstly have a poor medical prognosis,
unbearable pain or substantial impairment. The full discretion
of the person committing suicide is the second part. It is these
two with which we work within EXIT.
Q2404 Chairman: Is there any time
frame in relation to natural death? In some places a time within
which natural death is expected is set out as a requirement for
assisted suicide. Do you have that or not?
Dr Hotz: No, we
do not have that. For us the autonomy of the person is in a way
our first point of view. We are rather liberal on this medical
prognosis. If you have, for instance, a person who is over 90
and is fed up with life, has different pains but is not before
death, then we help. We interpret our rules. Of course, we look
at each case. With a 70-year old person we would not do that.
With a 90-year old we are more liberal to consider the autonomy
of a person.
Q2405 Chairman: We have understood
that general structure. I think it would be useful for us to know
in a particular case what the procedure is for the actual patient
and what happens, how you apply the conditions in a practical
example. Would that be possible?
Dr Hotz: Yes, of
course.Dr Zucco: As a rule we agree to assist people
who are members of our organisation. If somebody who is not a
member wishes to be accompanied then he has to become a member.
We have about 50,000 members in Switzerland. When one of these
members wants to be assisted in suicide then he has to apply specifically.
There is a first visit which we conduct with this person, and
based on this first meeting we decide if this is a case for EXIT
or not.
Q2406 Chairman: Who does the person
see on the first visit?
Dr Zucco: We have
a team of about ten people who do this assisted suicide and it
is one of this team. The first thing that we try to assess is
the capability of the person to make such a decision. If we are
satisfied with thatand, of course, this is not a permanent
decision; it is just a decision at first glance and there will
be more opportunities of confirming this assessmentthen
we try to establish the seriousness of the wish. We try to do
this over a certain period of time because there are people who
want to die today and tomorrow they want to live, so we try to
postpone the execution of the suicide as much as possible. If
finally the decision is made that the person can qualify then
we have to ask this person to provide us with two documents. One
document is a sort of diagnosis that he is supposed to get from
his surgeon or consultant and the doctor is supposed to do that.
He cannot refuse to provide that.
Q2407 Chairman: That is the person's
own doctor?
Dr Zucco: Generally
speaking, yes. He has to testify to the diagnosis and then say
if the disease would carry the person to death; in other words
if it is a terminal patient or not. The third point, which is
extremely important, is the confirmation of the capability of
the person to decide on this specific question. The second document
that we need is a prescription because all assisted suicides which
we practise at EXIT are done by using a barbiturate which, being
a narcotic, cannot be provided in a pharmacy just like that. You
need a prescription. This is a little bit of a stumbling block
because you need a doctor who is willing to do that, and of course
there is no forcing him to do that. It is his autonomous decision.
We are very happy if the family doctor does that because he is
the one who has known the patient for the longest time. If he
is not willing to do that because of ethical considerations or
religious considerations or whatever, there are a number of doctors
who work very closely with EXIT because they think in the same
way as we do, so normally we would resort to one of those. Once
we have the document from the family doctor and this prescription
then it is up to the patient to decide if and when he wants to
die. Then he just has to call the person who has been assigned
to him or her.
Q2408 Chairman: That is the same
person as he saw at the first visit?
Dr Zucco: It is
the same person. The patient has the possibility of refusing the
person. If the chemistry between two people is not okay then this
can be done. We have had such cases. However, generally speaking
the same person accompanies the patient all through this process.
We have found that generally speaking only one third of the people
for whom we open a case will also die with EXIT. The rest will
die a natural death or we lose contact with them. When the day
comes that has been fixed for the accompaniment we bring the barbiturate
with us and the procedure is exactly the same as you heard from
DIGNITAS. If you want I can repeat it but to save your time maybe
it is not necessary.
Q2409 Chairman: Could I just say
what I understand it to be, that is to say, once the patient comes
and the barbiturates are there with the person from EXIT then,
after confirming the situation is the same as it was before and
the patient still wants to have the barbiturates, the EXIT person
makes them available to the patient and the patient has them within
his or her reach and can use them if they are going to proceed.
Is that a reasonable summary?
Dr Zucco: Yes,
that is right, and the person who brings the barbiturate stays
until the end, until also all the formalities have been completed
with the authorities.
Q2410 Chairman: He telephones or
sends a message to the police authorities because it is an unnatural
death?
Dr Zucco: Exactly.
Q2411 Chairman: And then the police
come. Do you normally have an arrangement with the patient about
what is to happen thereafter in the way of disposal of the body
and so on? That is all arranged beforehand?
Dr Zucco: For a
certain part, yes, but the relatives of the person who dies have
the possibility of discussing this with the policeman that comes
because Switzerland is a very decentralised country.
Q2412 Chairman: Yes, very much so.
We have realised that.
Dr Zucco: In every
canton there are different rules. For instance, in Basel the corpse
of the person who has died has generally to go to a medical institute
for an autopsy. In all other cantons this is not a rule. This
is only done in cases where this is requested by the coroner.
Q2413 Baroness Jay of Paddington:
Could I just ask you a question about the issue of people who
cannot or find it very difficult physically to administer the
medicine themselves? Lord Mackay described, and you did not contradict
him, that you leave the barbiturates within reach of the person.
What happens with people who are very physically disabled?
Dr Zucco: Generally
speaking this medicine is administered orally, so we prepare the
solution that the patient has to drink and we put it on the table
and he or she is supposed to take the glass into his or her hands.
This is the normal way. If somebody is disabled and cannot do
that for some reason or, for instance, cannot drink because he
is paralysed or the stomach does not function properly, then there
is an alternative way of administering this medicine. This is
by infusion in the veins. The principle stays the same. The last
action has to be done by the person who dies, so this means in
this case opening a valve. This is done not very frequently but
in several cases. These are the two different options.
Q2414 Chairman: The valve is constructed
in such a way that, so long as you have the will to open it, it
is quite easy to open?
Dr Zucco: Exactly.
Q2415 Chairman: Like taking the top
off a bottle, for example?
Dr Zucco: It is
like a tap.
Q2416 Chairman: But very easy to
turn? Some taps are more difficult than others.
Dr Zucco: Yes.
Q2417 Chairman: The last act is the
patient's?
Dr Zucco: Yes.
As a matter of fact today there is no longer a tap in most cases.
There is a small wheel that they have to push.
Q2418 Chairman: We have heard it
said in some other places that it is something that you can squeeze;
you can open the thing by squeezing a valve.
Dr Zucco: No. Many
people are working at developing systems which allow people who
are very disabled to be able to commit suicide which would not
otherwise be possible. This is because several people who are,
for instance, tetraplegic are discriminated against because even
if their wish is very clear and very understandable they cannot
be assisted because they cannot move.
Q2419 Chairman: They do not have
any movement at all?
Dr Hotz: We try
in these cases to have two people, that the assistant from EXIT
has a witness, and there have been cases also where a video has
been made to prove afterwards that the person opened the valve,
which is of course a delicate action.
Professor Schwarzenegger:
We had a meeting with the prosecutor of the canton of Zurich
to discuss several methods by which tetraplegics and others could
commit suicide. Several technical measures have been proposed
and the public prosecutor has expressed doubts about the methods.
It is something which is decided in accordance with the authorities.
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