Suicide groups make Switzerland a final destination

ZURICH -- Long famous for secretive banks and soaring peaks, Switzerland is now gaining a reputation as a death destination, a country where desperately ill people can come to kill themselves with help from organizations.

''What we do is no secret; we're proud of our work," said Ludwig Minelli, founder of Dignitas, a Zurich-based group that assists ailing Germans, Britons, and others who want to die.

''Our purpose is to fight for the freedom of people to end their lives when their lives become unendurable" because of painful illness or old age, he said.

More than 2,000 people have received medically prescribed doses of barbiturates to kill themselves in Switzerland over the past 10 years, according to figures kept by the three main suicide organizations.

So-called assisted suicide is legal here as long as the agencies that arrange death do so for ''honorable reasons," without seeking profit, although they may charge basic fees.

Dignitas has raised concerns among prosecutors in other European countries by facilitating the suicides of non-Swiss, a legal gray area, arranging everything from travel tickets to funeral services, as well as the fatal dose. Minelli said almost two-thirds of his clients come from Germany and Britain, where doctors are forbidden from helping patients end their lives.

The Swiss connection is just one part of a wider debate ringing across Europe, as doctors, ethicists, politicians, and ''right to die" advocates square off over whether assisted suicide and even euthanasia -- presently legal in just two countries, the Netherlands and Belgium -- should be entitlements for the dying or the grievously ill.

The question of whether doctors should be allowed to aid in suicides is as bitterly disputed in Europe as in the United States, where a landmark Supreme Court ruling last month upheld Oregon's Death With Dignity Act. Oregon is the first American jurisdiction to legalize physician-assisted suicide.

In Germany, the discussion carries the weight of the country's horrific mid-20th-century history. Under Hitler, doctor-administered death was official policy of a state obsessed with ''genetic health." More than 250,000 infants, children, and adults with severe physical or mental disabilities were killed during the Nazi era, ostensibly to purify the Aryan race, according to historians.

Largely because of that history, medical professionals in Germany almost uniformly oppose ''death by doctor," despite public opinion polls indicating that a huge majority of citizens -- 82 percent, according to one survey -- favor legalization of assisted suicide.

A smaller percentage of the population supports Dutch-style medical euthanasia. Euthanasia is a mercy killing done directly by a doctor; assisted suicides are ones in which the deadly dose may be prescribed by the doctor or, as in Switzerland, obtained by a third party, but taken by the individual.

''We in Germany, with our history, should be most wary of promoting euthanasia or encouraging death," said Dr. Joerg-Dietrich Hoppe, president of the German Medical Association.

''The killing of a person -- and that, in the end, is what's at issue -- should not be the duty of a doctor," he said. ''The duty of a doctor is to preserve life and to restore health. When cure is impossible, the duty of the doctor is to alleviate suffering with palliative treatment, not a fatal dose."

Advocates of assisted suicide and voluntary euthanasia insist that it is the ailing individual, not doctors, who should make the choice of whether to live or die.

''Any pluralistic society must allow every citizen to live this last act of their life, that of choosing their own death," said lawyer Jacqueline Herremans, head of Belgium's Association for the Right to Die With Dignity. ''The feeling of the right to choose one's destiny is certainly growing in the [European] population."

The US Supreme Court decision has raised pressure on European lawmakers struggling to accommodate popular demands for a more permissive approach to ending life while preventing abuse.

Opponents of euthanasia and assisted suicide assert that the experiment in Holland has already gone awry and that doctors occasionally prescribe death for comatose patients, including those who have never stipulated a desire for death under a living will or some similar legal device, as well as for newborns with dreadful, but treatable, afflictions.

''In terms of public opinion, euthanasia seems to represent the easiest answer to complicated questions of life and death," said Henk Jochemsen, director of medical ethics for the Netherlands-based Lindeboom Institute, a Christian research group that opposes the practice. ''Europe has some aspects of a dying culture: It is aging. It feels heavy with history and has become rather pessimistic and gloomy. Support for assisted suicide and euthanasia is a discouraging sign of our times."

In 2001, the Netherlands legalized not only assisted suicide but also euthanasia. Doctors are authorized to directly administer lethal injections or pills to cogent, terminally ill people or to individuals in ''lasting, unendurable pain" who prefer fast death to an agonizing battle. About 3,800 Dutch a year opt for a fatal injection from a physician or a prescribed toxic overdose.

Belgium also permits voluntary euthanasia for people of sound mind but ''futile medical condition." In both countries, medical groups insist rigorous guidelines are followed.

Opponents say that huge danger lies in the moral and social pressures they believe are created by legalized euthanasia and, to a lesser extent, assisted suicide. In Holland especially, critics maintain, euthanasia has become such an accepted medical procedure that people who don't choose to die this way may be seen as selfishly using medical resources that could better help curable patients.

''Poor Grandfather, dying of cancer, may come to feel he should quicken the process, almost as his civic duty," said Hoppe. ''Even loving families can be manipulated into thinking that quick death is always preferable to lingering death. But perhaps Grandpa wants a few more weeks or months, even in pain."

Critics further say that once euthanasia becomes accepted practice for consenting adults, it inevitably raises thorny questions of whether to permit mercy killings of comatose patients or even newborns with terrible deformities. A study published in The New England Journal of Medicine last year reported that Dutch doctors have euthanized small numbers of infants born with severe afflictions, in technical violation of both the country's euthanasia law and the pledges made by politicians and activists who pushed for it.

The euthanasia of newborns remains illegal in Holland, but the practice continues under a set of protocols that, in essence, remove the risk of prosecution for doctors who follow medical guidance and report the procedure. The newborn must be perceived to be suffering greatly with no hope of improvement, and the parents must give permission. Mercy killings are administered to between 15 and 20 infants a year in Holland, according to medical studies, mostly to newborns with spina bifida, a defect of massive brain and spinal cord deformities.

Euthanasia for other ''people of no free will," including comatose patients and severely retarded or demented individuals suffering great pain from a terminal illness, remains a legal gray area in Holland. But medical studies quoted by European news media indicate that roughly 1,000 such individuals are euthanized in the Netherlands every year.

In Britain, a bill introduced this month in the House of Lords would grant a ''competent" individual suffering from incurable illness or unbearable pain the legal right to demand that doctors prescribe a lethal cocktail, although the patient would be required to administer the dose himself.

Archbishop Peter Smith of the Roman Catholic Archdiocese of Cardiff recently called the bill ''assisted killing" and said he believes the government could better help the dying by providing more money for hospices and institutions offering palliative care.

In Switzerland, suicide is legal, and the national penal code exempts from legal penalty those who help people kill themselves, so long as the assistance is rendered for ''honorable" reasons, such as bringing an end to suffering. This loophole has allowed groups like Dignitas to function as charities whose mission is to streamline the suicide process.

''We offer a solution for people in a dilemma, people either in great pain or fearful of slipping into dementia and becoming incapable of making their own final decisions," Minelli said.

Dignitas has helped 493 individuals kill themselves since 1998, more than half of them coming from Germany and Britain. Investigators in those countries have alleged that Dignitas has arranged the deaths of people who were neither dying nor even terribly ill.

''We do not want this travel agency of death," Elisabeth Heister-Neumann, justice minister for the German state of Lower Saxony, where Dignitas recently opened an office, told the Die Welt newspaper. ''The fear of pain requires treatment for pain, not death."

Meanwhile, a prominent teaching hospital in Switzerland last month became the first to allow assisted suicides on its premises under highly limited circumstances. The Vaud University Hospital Center in Lausanne will now permit terminally ill patients who have expressed a ''consistent desire" to die before entering the hospital, but who are too incapacitated to go home to take their own lives with help from Exit, another assisted-suicide group.

''It was a difficult decision. The mission of our hospital is to cure patients, not help them die," said Alberto Crespo, legal and ethical director of the hospital.

''But we have to respect the wishes of those patients who want to die, yet are unable to leave the hospital. We cannot deprive them of a right they would have at home, simply because they are in a hospital."

Petra Krischok of the Globe's Berlin bureau contributed to this report.