Examination of Witnesses (Questions 2420
THURSDAY 3 FEBRUARY 2005
SCHWARZENEGGER and MS
SARAH J SUMMERS
Q2420 Baroness Hayman: Have there
been very difficult cases with tetraplegics or people with advanced
ALS where you have not been able to help them despite their express
wish because they did not have the physical capacity to take the
Dr Zucco: In my
experience I never had any case like that. I cannot speak for
other people. I never heard that we had such a case, maybe because
we try to clarify the whole process from the very beginning.
Q2421 Chairman: So the prosecutor
is quite happy with a large degree of assistance, if I can put
it that way, in terms of getting the infusion ready and everything
else, as long as there is a discernible last act that is the patient's?
Dr Zucco: There
was some concern some time ago concerning this infusion and the
reason was that the prosecutor of Zurich thought that an
infusion required more preparation so that the patient might be
impressed by these preparations and might decide that now he has
to die because everything has got so far. Now it has been accepted
because what we do is keep asking until the last second, "Do
you really want it?". We try to make it easy for the patient
to say no.
Q2422 Chairman: If there was a big
assembly of preparation required would that be thought possibly
to put pressure on the patient, "Having gone this far I cannot
return", as it were, so that until the very last minute when
the patient's action of some kind is required, you keep telling
them, "You need not do this"?
Dr Zucco: Yes.
Q2423 Baroness Hayman: In terms of
your concern with the monitoring and the keeping to the rules
and the conditions, how do you verify that each of the people
who works as an accompanist is abiding by these rules and how
does the state do that? Is their view only retrospective, after
the event, or do they have any knowledge of your procedures or
checks or random checks and procedures?
Dr Zucco: We have
very frequent and strong supervision where cases, especially difficult
cases, are discussed and we from the team are supposed to follow
certain courses for improving our capabilities and for making
sure that we abide by the law. I must say that during all these
years, and EXIT was founded 23 years ago, there have been very
few cases where there were problems with justice, for instance.
It was mainly related to a company assisting people who had psychiatric
problems. This is several years back. The possibility for the
authorities to verify what has happened later on is almost impossible.
The only way is to have an autopsy of the corpse, but this can
only establish if the barbiturate was used, not much more than
that. Also, the clearness of the will cannot be established post
Q2424 Chairman: Do you normally have
a writing from the patient at the beginning if the patient is
able to authenticate a document? Do you get that at the initial
stage when they see your official in the first instance?
Dr Zucco: This
is not required but we are very glad if we get something like
this. There are patients who like to keep a sort of diary on the
disease so if we get copies of this, especially if it is handwritten,
we are very glad.
Q2425 Chairman: The authentication
afterwards that the law has been fulfilled depends, I suppose,
on seeing what sort of equipment there was there and whether there
was one of these things and then on the integrity of the relatives,
if they are there, and of your representative who is there?
Dr Zucco: Right.
Q2426 Chairman: It is normally just
one person from EXIT, is it?
Dr Zucco: Yes.
Dr Hotz mentioned that in special cases there would be a second
person. Generally speaking the second person who is always there
is not from EXIT. It is generally speaking a relative or a friend
or whoever. He or she has the function of a witness.
Q2427 Bishop of St Albans: I think
I may have missed something, which is the place where all this
happens. Is it usually in the patient's home? Where do most of
the assisted suicides happen?
Dr Zucco: In most
cases by far the patient dies at home. There are cases where the
patient does not have a home any more because they are in a public
institution. Zurich is different from the rest of Switzerland
because in old people's homes in Switzerland it is possible for
EXIT to become active, but for all the rest of Switzerland this
is generally speaking not allowed. In these cases it is difficult
because the person has no home. Actually, the old people's home
is his home. If he or she wants to die with EXIT he will have
to leave this home and then the only alternative is that EXIT
has a room in Zurich and one in Berne where these people
can come to die.
Q2428 Bishop of St Albans: Can I
follow up on a different subject which is about the exercise of
power by those who control the barbiturate? You were saying earlier
that personal autonomy is the key and yet, if I am 70 years of
age and I wish to exercise personal autonomy that you think I
should not, I cannot, so there appears to be a kind of exercise
of power by someone other than the patient over their own autonomy.
Have I misunderstood that?
Dr Zucco: There
are two aspects. One is EXIT and the other one is the doctors
who are supposed to write the prescription. There may be cases
where EXIT agrees to assist somebody but where no doctor is prepared
to make the prescription. Because we only use this barbiturate
then in these cases we have to stop. There is no way that we can
assist somebody. This is why other organisations have been looking
for different ways of assisting people who want to commit suicide
which would not require a prescription. There was one such organisation
in Switzerland, very small, and they had problems with justice,
so at present they cannot continue to practise. As far as EXIT
is concerned there has been some time ago a change of philosophy
because in the beginning EXIT was only prepared to assist people
who were terminally ill or had very strong pains or were disabled,
for instance, they had to spend their life in bed, and recently
it has been decided that we would also assist elderly people who
simply decide that they do not see any meaning in their life any
more. They have different problems, for instance, they do not
see well any more or they cannot leave their room or whatever,
but they would not die of this. These people we are now prepared
to assist. There is no opposition, let us say, from the authorities.
Q2429 Bishop of St Albans: Suppose
it was a 17-year old young person who was suffering from depression
or just wanted to die. Would you think that was an acceptable
thing for them to do?
Dr Zucco: You say
Q2430 Bishop of St Albans: Or whatever.
Dr Zucco: For depression
this makes a difference because this is what you can consider
a psychiatric disturbance and because this is a very controversial
subject EXIT decided about five years ago to stop assisting such
people even if, according to the law, this would have been completely
possible. Very recently there has been again a decision in the
other direction, that in selected cases where people who have
a psychiatric disturbance are very clear in their will they can
again be assisted.
Q2431 Bishop of St Albans: Could
you say on what moral grounds as opposed to legal grounds you
make these distinctions?
Dr Rippe: There
are two principles. It is not only the principle that follows
autonomy but also on the other hand we have the principle of care
or of benevolence and to make a responsible choice of the person
there has to be some evidence that it is their autonomous will.
For example, for the 17-year old person who has depression we
have to believe that he has tried all possible therapies. There
is a long dialogue with the person to make it clear that it is
his autonomous will, that he has considered all the facts and
all the options of his life and if his decision is well considered
with all necessary information and so on. Therefore we have always
two principlescare and autonomy.
Q2432 Chairman: In such a case you
would still need to get a doctor's prescription?
Dr Rippe: In all
cases there will be a doctor's prescription.
Q2433 Chairman: So the doctor's guidelines
will apply and in the 17-year old person's case the doctor might
take a different view of whether it was advisable and whether
in conscience he could decide to assist by granting a prescription?
Dr Rippe: I think
for a 17-year old boy or young lady with depression no doctor
will do it because they can be cured.
That is a legal question also and you can find in the documentation
that our medical legislation also prohibits doctors from prescribing
barbiturates in such cases. There must be an analysis of the case
and it must be well documented and only under these circumstances
is a doctor allowed to hand out a prescription. That is like a
third filter in the system which is a control mechanism beyond
the reach of autonomy. It is the medical legislation field which
could lead to punishment against the doctor and also to disciplinary
measures like revoking his licence. That is why this does not
Q2434 Chairman: It would be useful
to get a little bit more detail. This is medical legislation that
controls the barbiturate prescription?
That is right.
Q2435 Chairman: We have not actually
been referred to that unless it is in this document.
It is in this document. We have translated the provisions from
the law on pharmaceutical products where this is contained and
because it is a narcotic it also falls under the narcotics law.
This, in combination with the health law of the cantons, prohibits
doctors from issuing a prescription in such cases as you mentioned
before. This is like the third filter level after one has controlled
the legal capacity of the person and the second problem area is
whether the person is committing suicide and taking the last action
by himself or herself. This is a second important filter in our
system and the third one is the control over the narcotics. You
will find the details in the document.
Q2436 Chairman: I have just been
looking at them. On pharmaceutical products it says, "Prescribing
and dispensing of pharmaceutical products must be carried out
in accordance with the acknowledged rules of medical and pharmaceutical
science". Is it your view that in the case that the Bishop
has mentioned, of a 17-year old person suffering from depression,
the acknowledged rules of medical and pharmaceutical science would
not permit the prescribing of barbiturates in that situation?
That is right. They would indicate to treat the depression.
Q2437 Chairman: And you have given
us the narcotics law you immediately underneath and again it is
the acknowledged rules, this time of medical science, pharmaceutical
being missed out?
That is right.
Q2438 Baroness Hayman: Would there
also be an issue under Article 16 about legal capacity?
That is the first filter. That is what EXIT is taking a lot of
attention to filter out right from the start, that this is done
in the first contact.
Q2439 Baroness Hayman: The depression
could be a reason for saying that someone did not have capacity
and therefore did not get over the first hurdle?
That is absolutely right.
Dr Rippe: In the
case of depression no people from EXIT will prove that they have
the capacity to act autonomously, so there is a fourth filter
for these persons.
Dr Zucco: If there
is a case where depression is involved or psychosis or whatever,
then we request a certificate from a psychiatrist that this person,
in spite of that, is capable of deciding whether to live or to
die, and if the psychiatrist does not issue this document we have
to refuse the case.