Examination of Witnesses (Questions 2440
- 2460)
THURSDAY 3 FEBRUARY 2005
DR KLAUS
HOTZ, DR
GIANCARLO ZUCCO,
PROFESSOR CHRISTIAN
SCHWARZENEGGER and MS
SARAH J SUMMERS
LLB, EXIT
Q2440 Chairman: On the initial visit
of the patient he or she is seeing one of your people that work
in this area and the certificate that they have to get from the
doctor will normally bring out, will it, if there is any psychological
or psychiatric problem, because it might be difficult on a single
visit for somebody who was not a fairly well trained psychiatrist
to notice that there was something deficient about the person's
capacity? You rely to some extent anyway on the medical certificate
which at that stage you ask the patient to produce?
Dr Zucco: Right.
Anyway, if there is the slightest suspicion that somebody may
be psychologically ill it will be a long process. Even if the
case is accepted it is not going to happen very soon because there
will be more steps to go through to make it really very clear
that this is finally the will of the person.
Q2441 Chairman: As you have explained
before, people have cycles of ups and downs and you have to ensure
in the ordinary case even that it is a properly fixed determination
that is at the basis of the request?
Dr Zucco: Yes,
you are right.
Q2442 Baroness Finlay of Llandaff:
Moving away from competence for the moment, how do you determine
whether a person has been subject to coercion?
Dr Zucco: That
is a very good question. It is very difficult because it is very
difficult to know exactly what the family situation of a person
is. You can ask as many questions as you want but finally some
people are not even very willing to answer your questions on this
subject. I have already seen many people say, "This is none
of your business. This is our family affair". The best way
to make sure that we are accompanying the right persons is to
try to stay in touch with them over a longer period and have contacts
with them, for instance, even by telephone, and many things will
develop that you do not see during the first visit.
Q2443 Baroness Finlay of Llandaff:
I was wondering about the situation of an old person who is in
care, where the family are having to pay for the care and the
financial pressures are mounting. What do you do about those cases?
Dr Zucco: These
are from our point of view very difficult cases because sometimes
you can assume that there is pressure from the relatives but sometimes
it is the person himself or herself who wants to die, maybe because
he or she feels that he is putting pressure on the relatives.
These cases are extremely difficult to decide. What we have to
do finally is to make sure 100 per cent by talking repeatedly
to the person that this is really his or her wish to die. There
may be cases where we make the wrong decision. I cannot exclude
that. This is typical of every activity.
Dr Hotz: Maybe
in reality you have to realise that people who come to EXIT in
large part have terrible health problems, cancer mostly, these
people are in a terrible state and they want to die. You see relatively
quickly that they mean it and that there is not pressure from
the family. They are suffering, they have a terrible life. We
have about 150 cases per year and out of these 150 probably 100
are also urgent cases where we have to act quickly, so this problem
is probably not such a large problem. Then you have others maybe
who are not so sick but in my experience the people who decide
to come to EXIT and make an assisted suicide have a very strong
character. You need a strong character to fix a date and say,
"Saturday next week: that is the day I go". You just
do not do that out of pressure. These are very minimal exclusive
cases and I think even in these cases there would be a remark
in these talks, maybe even at the last moment. I think it is not
such a big problem. You have to see it in proportion. We have
about 150 cases in EXIT per year. That is not so many cases.
Q2444 Baroness Finlay of Llandaff:
And you said about 100 of those are cancer patients?
Dr Hotz: About
two-thirds, that is about right.
Dr Zucco: This
changes, of course, every year. Last year was the year when we
had the most cases. I will give you the exact figures. Last year
we had 154, the year before 121, and in the previous years it
was about 100. I still think that there are certain borderline
cases where you have to make a decision that maybe is not the
correct decision. This is a risk that perhaps we cannot avoid.
Q2445 Baroness Finlay of Llandaff:
I want to ask you about the cancer patients specifically if I
may. What are the symptoms that you are judging as requiring urgent
suicide?
Dr Hotz: Suffocating,
for instance.
Q2446 Baroness Finlay of Llandaff:
Breathlessness?
Dr Zucco: It depends
on the disease. If it is cancer it depends what type of cancer.
Q2447 Baroness Finlay of Llandaff:
Oh, sure, but what I was wondering was what interventions are
you making sure these patients have had to relieve their symptoms
before you give them their dose of barbiturate? Do you have a
procedure to make sure that they have had palliative care according
to one of the European protocols, that you are using the European
Association for Palliative Care pain control protocol, the protocol
for dyspnoea? Are you using consultants in palliative medicine
to see these patients for symptom relief to be sure that it is
their will, not the symptom, which has driven them to despair?
Dr Zucco: It is
very important to consider that. We are not the only interlocutors
of these people. They are in touch with their surgeons, with their
families, and these questions are being discussed back and forth.
Q2448 Baroness Finlay of Llandaff:
But we know that palliative care in Switzerland, with all due
respect, is not well developed.
Dr Zucco: It is
not very well developed. I have an example. In Basel there is
what we call a hospice. This is a place where people go to die.
When somebody who is an EXIT member goes to die there we are not
allowed to accompany him in that clinic. What normally happens
is that we have a three-party discussion: the patient, somebody
from the hospice and somebody from EXIT, and we offer the patient
two different approaches. One is the EXIT approach and the other
one is the palliative care approach which in Switzerland maybe
is not very well developed but it goes very far. When I say it
goes very far I mean that the doctors are prepared to give the
patient very high amounts of morphine, for instance, to control
their pain and by doing this very often the death process is accelerated.
What happens in fact is that the patient can say, "I take
the EXIT approach, which means I have to go home again and then
I have to drink this barbiturate so it will be a matter of minutes
to die", or he can accept the alternative offered by the
hospice, which is that in two or three weeks he does not get any
food any more, he gets high doses of morphine and finally he is
going to die that way. It is up to the patient to decide. What
is always very important in our opinion is that the patient sees
the different alternatives that he has and by having these meetings
with all the people involved you are very sure that the patient
finally decides what he thinks is good for him.
Q2449 Lord Joffe: You have written
guidelines and principles which set out your policy and how you
go about it. Could we have copies of these documents?
Dr Zucco: We have
our statutes and then we also have guidelines, recommendations.
Q2450 Lord Joffe: Could we get copies
of these documents?
Dr Hotz: Those
are our internal documents which we are not handing out except
to the police authorities. The police authorities have these guidelines
but we do not give them to everybody. That is an internal paper
which is restricting us and we want to keep certain literature.
There are always exceptional cases and we do not want that suddenly
somebody comes and says, "Oh, this is against the recommendation
you have". We sometimes have very unusual cases. We have
the Ethical Commission which decides about these very unusual
cases and we do not want to be too much restricted with those
patients. We also have the Compliance Commission. We check on
every case where there has been a going and in other cases where
we were not active. We check every person together with these
recommendations.
Q2451 Chairman: You gave us numbers,
151, I think.
Dr Zucco: 154 last
year.
Q2452 Chairman: Is that for EXIT
in one area of Switzerland or is it for the whole country?
Dr Hotz: That is
EXIT in the German speaking part and the Italian speaking part.
Dr Zucco: I do
not know if you have been informed about that. There are two EXIT
organisations. They are separate. They just happen to have the
same name because they were founded by the same person. There
is one EXIT for the Swiss alone, which is the French speaking
part of Switzerland. Our EXIT is responsible for the German speaking
part and the Italian-speaking part. The figure of 154 covers the
German speaking part and Ticino.
Chairman: Can you give
us the population and the total number of deaths in the area covered
by your EXIT, that is, the Italian and the German speaking parts?
I just want to get an idea of the proportion of assisted deaths
in your organisation in relation to the total number of deaths
and the total population of that area.
Q2453 Baroness Hayman: Perhaps the
total number of suicides as well.
Dr Zucco: A study
has been done in the past covering about ten years. During these
ten years, which was up to the year 2000, it used to be that the
people who died with EXIT were about five per cent of people who
committed suicide. It was about 0.1 per cent of the total people
who died during that time. Recently, because the number of accompaniments
has increased, it is approaching ten per cent of suicides.
Professor Schwarzenegger:
You can give us an address and we can send you the study because
it is available in English. That is one point. The second point
is that I was never informed that the palliative care in Switzerland
is at such a low level. That is a new thing for me. Legally I
think it is assured that the autonomous decision by the patient
is kept up, so that means either he can select palliative care
and then he enters into this indirect active euthanasia debate,
which is allowed according to Swiss criminal law, or he takes
the EXIT way which was described before, which means assisted
suicide where it must be an autonomous act by the person himself.
It is not that people are under pressure to select EXIT or commit
suicide, at least according to my studies.
Q2454 Chairman: I think the point
is that obviously, as Dr Zucco and Dr Hotz said, perhaps Dr Hotz
particularly, some of these people are very ill and so there is
no question about particular types of pressure. It is a pressure
of the illness that is so obvious, but the pressure of the illness
can be affected by the extent to which good palliative care is
available and I think that is probably the relevance of palliative
care to what we are concerned with.
Professor Schwarzenegger:
Of course.
Dr Rippe: There
is no contradiction between these two ways. In EXIT there is general
agreement that it would be better to have more palliative care
in Switzerland. Switzerland has its own foundation which puts
money into the palliative care field. The most important point
is to see if the person is autonomous or forced by the disease
and then the possibility to choose between these two options,
but we fully agree that there should be more palliative care in
Switzerland. It is not so bad but it is bad enough.
Chairman: It is not an
uncommon situation the world over.
Q2455 Baroness Hayman: I have a very
quick question about residence qualifications. You explained to
us that you disagree with DIGNITAS about non-residents. I think
I saw some figures that it is not nationality that you work on;
it is the issue of residence.
Dr Zucco: Yes.
Q2456 Baroness Hayman: Could you
tell me what the qualifying period for residence is to be a member
of EXIT?
Dr Zucco: There
are no rules from the side of EXIT but to become a resident in
Switzerland is not an easy thing. It is excluded that somebody
can become resident because he wants to die in Switzerland. This
would be a very long term thing that would be required.
Q2457 Chairman: It is the general
legislation that determines when you can become a resident.
Dr Zucco: Yes.
Q2458 Baroness Hayman: So if I were
an expatriate working here and the first week I was working here
I wanted to join EXIT I could not?
Ms Summers: Probably
if you were working here you would have a resident permit as an
expat.
Dr Rippe: I think
that is two questions.
Q2459 Baroness Hayman: It is the
definition of residency that is the key point.
Dr Rippe: The other
question is whether EXIT will do it. That is an open question.
Dr Zucco: We handle
that from case to case. We also have cases of people coming from
abroad to die here. We want to be flexible on this subject. We
do not want to promote this suicide tourism but on the other hand
if somebody in the UK has relatives in Switzerland, for instance,
the mother lives in Switzerland and the son is in the UK, and
the son wants to die with EXIT, in such a case we may decide that
we accept the case. It depends very much on the circumstances.
There was a case recently of a German citizen who had lived in
Switzerland for 20 years and then he went back to Germany. He
is still a member and if he should decide that he wants to die
with EXIT we would accept the case. That is why we do not have
very strict rules of residency.
Q2460 Baroness Hayman: It is not
the minimum three months, six months? You do not have a rule like
that?
Dr Zucco: No.
Chairman: Can I thank
you very much indeed, all of you, for your help. Sarah, you have
not had a chance to contribute but I know you contributed to the
paper. Thank you very much indeed.
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