Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence

Examination of Witnesses (Questions 2400 - 2419)



  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 that—and, 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 assessment—then 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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