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ASSISTED SUICIDE

How were two healthy American sisters able to take their own lives in Switzerland?

An unresolved mystery is surrounding the death of two healthcare workers from the US state of Arizona who reportedly came to Switzerland for a vacation but never returned home. This is what the authorities say happened to them.

How were two healthy American sisters able to take their own lives in Switzerland?
Assisted suicide in a Swiss clinic is legal under certain conditions. Photo by Bret Kavanaugh on Unsplash

As reported in the US media on Tuesday, the sisters, Lila Ammouri, 54, and Susan Frazier, 49, a doctor and nurse, took a trip to Switzerland on February 3rd, telling everyone they were going on vacation.

But when they didn’t return on their February 13th flight home, their family and friends began to worry.

After the US State Department got involved in the mystery disappearance, it turned out the two women, who were reportedly healthy and happy, died by assisted suicide in a Basel clinic — a plan they kept secret from everyone.

This information was confirmed by the Basel-Country’s public prosecutor’s office.

More questions than answers

The question of why the sisters chose to die and why they came all the way to Switzerland to do so when nine US states allow assisted suicide may remain unanswered.

While the women’s friends and family believe foul play was involved in their death, Basel’s prosecutor said no criminal investigation has been launched as the assisted suicide took place “within the legal framework” and no crime was committed.

That’s because Swiss legislation permits assisted suicide under certain conditions: if the patient is over the age of 18, mentally and physically capable of making the decision to die, and administers the drug him/herself  in a private residence.

Also, the person assisting in the suicide must not have any selfish motives.

If a third party administers the drug, the act is considered euthanasia, which remains illegal here.

READ MORE: What you need to know about assisted suicide in Switzerland

Membership and paperwork

A sign that the sisters had been planning their death in Switzerland for a while is that it is not possible for anyone to just walk into a clinic and ask to be put to death right there and then (as gruesome as it sounds).

The process includes making first contact (either directly or through a family member), personal interviews, counselling, and loads of paperwork. It can take three months or longer, as it involves becoming a member of a right-to-die organisation and paying all the administrative fees — amounting to several thousand francs — for cremation and other expenses, upfront. A prescription for lethal medication will then be ordered from a doctor.

There is even more paperwork involved when foreigners choose assisted suicide in Switzerland and this can be time-consuming as well.

To ensure that the process complies with the law, a video is shot of the patient stating their name, date of birth and that they understand what they are about to do. The camera keeps rolling as they open the valve that allows a barbiturate to begin flowing into their vein. This footage is used as evidence that they willingly took their own life.

That Basel authorities are not filing charges in the case of the two sisters implies that all processes leading to their death complied with the rules.

Can healthy people choose to die this way?

Neither Ammouri nor Frazier reportedly suffered from terminal or incurable medical conditions, so why were they allowed to commit suicide?

Only three conditions have to be fulfilled for assisted suicide in Switzerland: the person wishing to die has to have her/his decisional capacity; opens the valve him/herself, and the assisting person must have no selfish motive.

No specific restrictions relating to the ground of suffering are mentioned in the law.

While some organisations, like Exit, apply stricter criteria to the notion of illness and suffering — for instance, the patient has no chance of recovery, or lives with chronic and unbearable pain or disability — Swiss legislation in this matter doesn’t specifically apply to physical illness.

Mental distress, also defined as “existential suffering”, while decidedly a bit of a grey area that lacks definition, also falls under the “suffering” category.

According to a report co-authored by two Geneva medical ethicists, “suffering is surely not limited to disease status. If we consider relief from suffering to be one of the central considerations for assisted suicide, it is reasonable to think that the acceptability of a request should not exclusively depend on the diagnosis of an incurable or terminal disease”.

For instance, one of the Swiss right-to-die organisations, Pegasos — reportedly the clinic where the sisters died — says on its website it “believes that for a person to be in the headspace of considering ending their lives, their quality of life must be qualitatively poor. Pegasos accepts that some people who are not technically ‘sick’ may want to apply for assisted suicide”.

READ MORE: Switzerland: What is the difference between assisted suicide and euthanasia?

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For members

ASSISTED SUICIDE

EXPLAINED: How foreigners can access assisted suicide in Switzerland

Assisted suicide is legal in Switzerland. Despite concerns of suicide tourism, it can be accessed by foreigners.

EXPLAINED: How foreigners can access assisted suicide in Switzerland
Foreigners can access assisted suicide in Switzerland. Photo by Marcelo Leal on Unsplash

Assisted suicide is legal in Switzerland on compassionate grounds. 

While article 115 of the Swiss penal code prohibits assisted suicide for “self-serving reasons” and article 114 prohibits “causing the death” of a person for “commendable motives, and in particular out of compassion for the victim”, assisted suicide for non-selfish reasons is not specifically prohibited as long as certain conditions are met. 

This is relatively rare, both in Europe and worldwide. Only a handful of countries allow for some form of assisted suicide, including the Netherlands, New Zealand, Spain and Canada. 

Some American and Australian states allow for assisted suicide, despite not being permitted at a federal level. 

As a consequence, Switzerland has become a potential destination for people seeking assistance to end their life. 

But what are the rules for foreigners accessing assisted suicide in Switzerland? Here’s what you need to know. 

What are the rules for assisted suicide and euthanasia in Switzerland? 

One important distinction to make is between euthanasia and assisted suicide. Assisted suicide still requires the person in question to administer the suicide themselves, while euthanasia is where a doctor takes this final step. 

Euthanasia is not permitted in Switzerland, while assisted suicide is allowed for both locals and foreigners. 

READ MORE: What you need to know about assisted suicide in Switzerland

The main associations administering assisted suicides are Exit, Dignitas, Ex International, and lifecircle.

Exit and Dignitas are the largest groups in Switzerland.

Exit only provides assistance for citizens or long-term residents of Switzerland while Dignitas is the only organisation to provide assisted suicide services to foreigners.

According to Dignitas, assisted suicide is popular among foreigners, with 90 percent of those who received help dying in 2018 coming from abroad. The majority of those who received assisted suicide were German. 

How can foreigners receive assisted suicide in Switzerland? 

In order to access assisted suicide as a foreigner, you will need to become a Dignitas member. This can be done from abroad, provided you are deemed to be of full mental capacity and are an adult. 

You need to apply on the website and will need to fill out a form and provide a declaration of membership. 

Once this is accepted, you will receive an invoice with payment instructions.  

How much does it cost to receive assisted suicide in Switzerland? 

While the direct costs of having an assisted suicide process administered in Switzerland are relatively low, the indirect costs are high. 

In order to join Dignitas, it will cost you a one-off fee of 200 Swiss francs, followed by an annual membership fee of 80 francs.

However, while this might seem cheap, there are other costs to consider – particularly if you are a foreigner. 

The UK-based Campaign for Dignity in Dying, an organisation which agitates for greater access to assisted suicide, estimates that it costs between £6,500 (CHF8,269) to over £15,000 (CHF19,080) for each person receiving assisted suicide in Switzerland, at an average of £10,000 (CHF12,720). 

These costs include travel costs to Switzerland, along with accommodation costs and medical expenses. 

Many of those interviewed said they also booked return flights which they didn’t intend to use in order to not arouse suspicion among the authorities and to have an option in case they changed their minds. 

How long will the process take? 

Dignitas says the process can take three months or longer to become a member. 

Dignitas specifies that for non-members, submission of a declaration of membership is a mandatory first step although it also notes there is no waiting period between become a member and applying for assisted suicide.

In order to receive assisted suicide with Dignitas, you will need to go through a processes that includes making first contact (either directly or through a family member), counselling and personal interviews, submission of medical documents and an exploration of other treatment options including palliative care. 

A prescription for lethal medication will then be ordered from a doctor.

Dignitas also notes there is a lot of paperwork involved when foreigners choose assisted suicide in Switzerland and this can be time-consuming.

Dignitas is a non-profit organisation which invests all of its surplus money in expanding its services as well as providing suicide prevention advice. 

A 2011 referendum in Zurich sought to target foreigners by making assisted suicide legal only for residents, however this was rejected at the ballot box by 78 percent. 

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