A “suicide pod” in Switzerland roils the right-to-die debate.
by Marin Cogan
Dec 26, 2024
VOX
Drew Shannon for Vox
VOX
Drew Shannon for Vox
LONG READ
The pod looked like a tanning bed from another planet: a human-sized chamber, white and sparkly purple with a clear glass door, resting on an inclined platform. Previously, it had been on display in public exhibitions, but now it was in Schaffhausen, in a large park in northern Switzerland, near the border with Germany.
A woman stood in front of it, under a dense canopy of trees. She wore a white fleece jacket, dark pants, and flip-flops. It was late September 2024, and the air in this part of the country had become cool.
The woman, a 64-year-old American whose name has not been made public, had come to the Alpine country, to this place of vineyards and rolling meadows and mountain views, to end her life.
It was a private decision that, paradoxically, would have global implications for the debate over end-of-life care and whether people have a right to medically assisted suicide.
For more than 25 years, Switzerland has been a destination for people who want a medically assisted suicide, thanks to the country’s longstanding and liberal law regarding the practice. Each year, the number of people choosing assisted suicide in the country grows; in 2023, that number reached more than 1,200. Most people who end their lives in Switzerland are elderly or have an incurable illness, though a person can sometimes get approval for an assisted suicide under other circumstances. And though the majority who die this way are citizens, Switzerland is one of the few countries that also allows foreigners to travel there for the purpose, a practice critics have derided as “suicide tourism.”
The country’s largest assisted suicide nonprofit, Exit, takes only citizens and permanent residents. But other prominent organizations, including Dignitas and Pegasos, accept foreigners. People who are interested reach out to the groups online and apply for membership, which provides counseling and guidance around end-of-life care. Those seeking a medically assisted death are required to have consultations with a doctor associated with one of the organizations. After determining that the person is eligible, of sound mind, and, when applicable, has considered their full range of treatment options, the doctor writes a prescription for sodium pentobarbital, the same substance used for pet euthanasia and many lethal injection executions in the US, to be used at a later date chosen by the patient.
The doctor is not allowed to administer the medication themselves. That practice is known as euthanasia, which is not legal in the country because it is considered “deliberate killing.” Instead, they provide the medication to the patient, who, in the presence of the doctor or an aide for one of the organizations, either swallows it or takes it with a gastric tube or an intravenous infusion.
The entire process, for foreigners, costs about $11,000 and usually takes a couple of months.
Had the American woman chosen to end her life under the standard Swiss protocol, it probably wouldn’t have been controversial. She reportedly had skull base osteomyelitis, a rare and painful inflammatory condition that is often fatal if untreated. She told the group helping her that her adult children fully supported her decision.
But she wasn’t there to end her life the standard way. Instead, she was about to become the first person to try a controversial new method for suicide, using a technology that would roil public debate over assisted suicide in Switzerland and capture attention around the globe.
She would use the Sarco pod, an invention of Philip Nitschke, a strident right-to-die advocate. Nitschke hopes that the 3-D printed pod, with a name that’s short for sarcophagus, will revolutionize the practice of voluntary assisted death by taking doctors out of the picture.
The Sarco, he has said, doesn’t require a lengthy screening process or thousands of dollars. Rather than relying on sodium pentobarbital, a person who wanted to use the pod could buy nitrogen. They would lie down inside the pod, resting their head on a neck travel pillow. Then, they would close the door and push a button. The chamber would fill with nitrogen gas, and oxygen levels would quickly drop below levels humans need to survive.
As a method of execution in the US, nitrogen hypoxia has been highly controversial. Earlier this year, UN experts raised concerns that the execution of Alabama death row inmate Kenneth Eugene Smith using nitrogen gas could constitute “torture,” and the state is currently being sued by another inmate alleging the practice is cruel and unconstitutional. Right-to-die advocates, though, say that when administered properly, it’s a relatively painless death because people exposed to high levels of nitrogen quickly lose consciousness.
The American woman entered the chamber just before 4 pm, according to Dutch newspaper de Volkskrant, which had a photographer in the woods of Schaffhausen before and after the death to document the scene. To protect against the possibility that they might be accused of foul play, Nitschke and his colleagues also set up two video cameras to record. Then Nitschke went across the border to Germany, possibly to avoid the risk of arrest. The only person who remained with the woman at the scene the entire time was Florian Willet, a colleague of Nitschke’s who co-founded The Last Resort, an organization to promote the Sarco pod’s use in Switzerland.
Seconds after entering the pod, the woman pressed the button to release the gas. Willet waited with her, monitoring her vital signs on an iPad and relaying them to Nitschke over the phone. After confirming her death, Willet called the police — a standard practice after an assisted suicide in Switzerland.
Typically, police examine the scene to verify that there are no signs of foul play.
But this wasn’t a typical death. Police arrested Willet, his attorneys, and the de Volkskrant photographer nearby on suspicion of “inducing and aiding and abetting suicide,” according to Reuters.
More than eight weeks later, Willet remained in jail, with police investigating the woman’s death as a possible “intentional killing.”
And Switzerland, a country that has for decades maintained a public consensus in support of assisted suicide, has been confronted with a series of questions that have implications for one of the most significant moments of every person’s life: To what extent should people have the right to determine when and how they die? What are the moral and philosophical implications for a society that sanctions the practice of medically assisted suicide? How does a nation handle the need for the safety of vulnerable people while also protecting their dignity and individual rights?
Switzerland isn’t the only country that allows assisted suicide. Other nations, including the Netherlands, Belgium, Luxembourg, Colombia, Spain, and Canada, also permit the practice, which some advocates call medical aid in dying (MAID) to differentiate it from the usual connotations of the word “suicide.” In late November, the British Parliament took the first step to pass a bill that would legalize assisted dying for some terminally ill patients.
In some countries, the law goes further than it does in Switzerland, allowing voluntary euthanasia, where doctors can administer lethal doses for patients who can’t or don’t want to do it themselves. Belgium and the Netherlands, for example, allow physician-assisted euthanasia for mental illnesses if a doctor determines that the condition creates unbearable suffering. What constitutes unbearable suffering, though, is inherently subjective and open to interpretation.
The number of deaths via euthanasia in both countries has grown considerably in recent years; the same is true of Canada, which recently passed some of the world’s most liberal euthanasia laws. Critics worry that the easy availability of assisted death creates incentives for people to see it as the only solution to their suffering, even when there might be effective treatments. They also worry about a “slippery slope” where doctor might approve assisted suicide for more and more reasons, ultimately resulting in suicides for non-medical reasons being enabled by law.
The United States does not permit euthanasia, but physician-assisted suicide is legal in 10 states, including California, Oregon, and Washington. According to a Gallup survey earlier this year, 71 percent of Americans believed that a doctor should be able to administer a euthanasia drug if requested by a patient or their family member, and nearly the same amount supported physician-assisted suicide for people with terminal illnesses.
Erika Preisig, a family physician and founder of the organization Lifecircle, which helps foreigners come to Switzerland for assisted suicide and advocates for other countries to legalize it, says the issue is going to become more important as more baby boomers reach the end of their lives.
“They will not let others decide how they have to die. They will decide themselves,” says Preisig, who is a member of that generation. “This will raise the percentage of assisted dying all over.”
Drew Shannon for Vox
But even with widespread support, the practice is still controversial in the US and elsewhere. The American public, despite supporting legalization, is more divided on the morality of doctor-assisted suicide. It’s opposed by the Catholic Church and other Christian organizations, which believe the practice goes against God’s will. Some disability rights advocates have argued fiercely against it, saying that it allows medical professionals to offer disabled people death rather than finding ways to improve their lives. The American College of Physicians (ACP) also opposes medically assisted dying on the grounds that the practice is incompatible with a doctor’s duty as a healer who takes the Hippocratic Oath, promising to do no harm.
“[T]he focus at the end of life should be on efforts to prevent or ease suffering,” the ACP’s president said in 2017. Partly as a result of those disagreements, Americans have different rights regarding assisted suicide depending on which state they live in. That’s led some Americans, including the woman who used the Sarco pod, to come to countries like Switzerland to end their lives.
The birthplace of Calvinism and an intellectual center of the Protestant Reformation, Switzerland has a long history of bucking the dogma of the Catholic Church and charting its own moral and philosophical path. Famously neutral during the World Wars, and now home to world governing bodies like the United Nations and the World Health Organization, the country can appear to be a tightly regulated place like many other Western European countries.
In reality, it’s a society built on compliance with social and cultural norms moreso than government regulations. Political scientists point to it as among the most libertarian societies on earth, and Switzerland is consistently ranked as the number one country in the Human Freedom Index report put out by the Cato Institute, a libertarian think tank.
Assisted suicide is no exception. The practice has been permitted in Switzerland longer than in any other country. In 1942, the government put into effect a statute outlawing abetting assisted suicide for “selfish purposes,” like gaining access to an inheritance, but otherwise, it wasn’t explicitly banned — which meant that, by omission, assisting suicide for non-selfish purposes was technically legal. To this day, the 1942 statute is the only law explicitly referring to assisted suicide. In an email to Vox, the prosecutor in charge of the case confirmed that Willet was arrested under suspicion of breaking this law.
In place of those laws, requirements for obtaining a medically assisted suicide were developed by doctors and codified into guidelines maintained by Switzerland’s medical professional organizations. The regulations are nonbinding, but disobeying them can in theory lead to professional sanctions. In practice, this has meant that the doctors are regulating themselves.
“We have one of the most liberal systems in the world,” Yvonne Gilli, the president of the country’s professional association for doctors, told Vox in an email. For most of the medical community, the desire seems to be to keep it that way. “We would therefore do well to leave doctors in a central role in assisted suicide,” Gilli wrote.
In a small, relatively homogenous nation of just under 10 million people, assisted suicide has never been quite the culture war issue it was in the United States in the 1990s and early 2000s, when Dr. Jack Kevorkian, a right-to-die advocate nicknamed “Dr. Death” by the media, filmed himself performing a voluntary euthanasia and sent the video footage to 60 Minutes, intentionally triggering a trial that would result in his conviction for murder.
In 2011, a referendum that proposed a ban on assisted suicide in Zurich, the country’s most populous canton or state, was rejected with 85 percent of the vote. That high level of public support has allowed assisted suicide organizations to operate with relatively little friction and without much public debate, even as demand increases. According to a long-term study of assisted suicides in the country from 1999-2018, the total number of physician-assisted suicides doubled every five years.
“Suicide assistance has been quite calm. The Swiss assisted suicide organizations were under the radar; there wasn’t much discussion about them,” says Bernhard Rütsche, a professor at the University of Lucerne and an expert on assisted suicide in Switzerland. “They care for their reputation. The whole branch of suicide assistance has been shaken up with this new method, and they don’t like that, quite understandably.”
The intervention of Nitschke and his Sarco pod threatens to upend the status quo.
In 1996, Nitschke became the first doctor in the world to help a terminally ill patient die legally by assisted suicide in Australia. A decade later, he and his partner Fiona Stewart published The Peaceful Pill Handbook, a guide that provides information about methods of assisted suicide and describes the process of obtaining one in Switzerland.
Nitschke, according to Katie Engelhart’s book The Inevitable: Dispatches on the Right to Die, began his work believing that patients with terminal illnesses should have the right to choose an end to their suffering. But as his advocacy deepened, his thinking evolved. Why should doctors like him be the one to make the decisions? Why should doctors get to determine what counts as extraordinary suffering and what doesn’t?
Over time, Nitschke came to believe that the right to die should be entirely in the hands of individuals and not medical professionals. The deeper his advocacy became, the more he clashed with other members of the medical community. He burned his medical license in 2015 after a protracted battle with Australia’s medical board. He also became more critical of mainstream MAID groups that focus only on the sickest patients.
He takes issue with the Swiss system, which he has said is too deferential to doctors and too expensive. “We are convinced that no money should be charged for an assisted death. Especially when you realize that it is already very expensive for foreigners who wish to die to travel to Switzerland,” Nitschke said of his organization, Exit International, in a recent interview. (Exit International, which is not related to the Swiss group Exit, pointed to statements on their website and declined to be interviewed before deadline.)
Nitschke approaches end-of-life issues with the zeal of a libertarian techno-futurist. In interviews, he’s spoken about a future where the Sarco pod’s blueprints are posted online, allowing anyone to 3-D print one anywhere in the world. He has said that AI could replace doctors in assessing whether a person meets the criteria to end their life. “We really want to develop that part of the process so that a person can have their mental capacity assessed by the software, rather than … spending half an hour with a psychiatrist,” Nitschke told Wired.
Nitschke’s unapologetic belief that people should be able to choose how and when they die, combined with his confrontational style, has made him a lightning rod for controversy, leading some of the doctors who support assisted dying to think that he does more harm to their cause than good.
“Nitschke wants to give everybody, without thinking, the possibility to die. For me, this is unethical,” says Preisig, the founder of Lifecircle. “This is very bad for Switzerland. It’s a big problem for us.” Leaders of other assisted suicide organizations have also been critical.
The debate over the Sarco pod has even reached the Swiss government. Nina Fehr Düsel, a member of the Swiss National Council (which is similar to the US Congress), has made a motion for the National Council to discuss assisted suicide in the coming months. She’s also asking her colleagues to consider banning the Sarco pod explicitly.
“I don’t want to overregulate this,” Fehr Düsel, a member of the populist right-wing Swiss People’s Party, which controls the most seats in the federal assembly, tells Vox. She has concerns about the use of nitrogen, which is at this point cheap and easy to obtain in the country. In general, she says, the organizations that are already established in the country should be left alone. “We already have these two longstanding organizations and that is enough,” Fehr Düsel says.
For others, the Sarco pod case has merely exposed the extent to which assisted suicide is operating without clear legal guidelines. “We need some regulation that ensures that autonomy is safeguarded and capacity is properly assessed, and the means for suicide assistance — the instruments and the medications — are safe and comply with human dignity,” says Rütsche, the professor at the University of Lucerne.
According to Rütsche, the government should codify the existing standards doctors have established, with laws around the assessment of someone’s capacity, obligations to provide information and counseling to make sure the decision is well considered, requirements for how the process takes place (including what drugs and devices are allowed and what aren’t), and oversight for the assisted suicide organizations — with the ability to ban a group for flouting the guidelines.
Whether Switzerland moves forward with a new law remains to be seen. But the Sarco pod’s future seems more certain.
Drew Shannon for Vox
Police confiscated the pod at the scene of the woman’s death. In November, Schaffhausen prosecutor Peter Sticher confirmed to Vox in an email that one person remained in police custody regarding the investigation. Willet, according to The Last Resort’s website, has been held in jail for two months.
Holding someone that long on suspicion of abetting a suicide for selfish purposes is highly unusual. But in late October, de Volkskrant, the Dutch paper, reported another reason that may explain Willet’s long detention: According to court records, a forensic doctor told investigators the woman was found with injuries to her neck, raising the possibility that Willet was the subject of an “intentional killing” investigation.
“The allegation of a [killing] is simply not true, and I’d guess everyone involved knows this,” says Andrea Taormina, the lawyer for the photographer who was detained after the woman’s death. “There are no facts that would indicate differently. This is mainly an allegation brought forward simply to raise the stakes in this procedure.”
De Volkskrant, which had access to and reviewed the camera footage, said in their report that nothing on the recording showed Willet opening the pod or doing anything to disturb the woman.
Ultimately, after 70 days in detention, Willet was released in early December.
Exit International and The Last Resort, Nitschke’s organizations, celebrated Willet’s release. “The allegation of intentional homicide was, and remains, absurd,” it said in a statement.
But in response to an email, Sticher told Vox that both investigations remained open. “All persons are still under investigations, for aiding and abetting a suicide for selfish purposes and for intentional homicide,” Sticher wrote. “But we had no more reasons to keep this last person in custody.”
While the drama brought by the Sarco pod’s use is exceptional, the broader debate shouldn’t be.
According to a UN report from 2023, the world population of people over 65 is expected to double, from 761 million in 2021 to 1.6 billion in 2050. In 25 years, people over 65 will make up 1 in 6 people on Earth — part of a global trend toward aging. Thanks to legalization in several countries, many of these people now know that physician-assisted suicide is an option. Assisted suicide remains rare, both globally and in the US. But as more attention is paid to it, the moral, philosophical, and political questions that the case prompted will only become more urgent.
In Switzerland, where assisted suicides are still a relatively small percentage of overall deaths, supporters say it’s important to maintain that right. “Modern medicine is keeping people alive longer and longer. This is why there are more and more very old people, and therefore more and more medical problems towards the end of life,” Marion Schafroth, the president of Exit, said in an email. “Human support for suicide is certainly not morally wrong. It serves the dignity and self-determination and safety of those who wish to die.”
Even if they don’t ultimately choose assisted suicide, says Preisig, the founder of Lifecircle, it’s important for people who are seriously ill to know they have the option. “People are not afraid of death, they’re afraid of unbearable suffering,” she says. “When they know they could [die] if they wanted to, then they lose this fear of unbearable suffering. This is the most important point for me.”
Still, other countries, like Canada, are grappling with serious concerns about whether the criteria for approval is expanding too quickly, enabling or even encouraging people who aren’t suffering to end their lives.
Canada’s Medical Assistance in Dying (MAID) program is a primary example for critics of what can go wrong. When MAID was first legalized in 2016, Canada had strict criteria: It was only to be used to end unbearable suffering in patients whose conditions were advanced and whose impending death was reasonably foreseeable.
In 2021, following a court ruling, the government removed the criteria that a death be reasonably foreseeable. Stories emerged of people who had been approved for euthanasia who didn’t have terminal illnesses. Health care workers have said they’re struggling with the ethical implications arising from people requesting euthanasia not for incurable illnesses but because they’re on government subsidies, were recently widowed, or are dealing with chronic but nonfatal conditions like obesity. And in October, a Canadian committee found that people had received approval for euthanasia for reasons such as social isolation.
Some disability rights groups in Canada are challenging the country’s expanded MAID laws in court. “We are witnessing an alarming trend where people with disabilities are seeking assisted suicide due to social deprivation, poverty, and lack of essential supports,” a leader of the group, Inclusion Canada, said in a statement in September. “This law also sends a devastating message that life with a disability is a fate worse than death, undermining decades of work toward equity and inclusion.”
The controversies around these cases, like the Sarco case, are raising uncomfortable questions for which there might not be easy answers. A legalized assisted suicide program without strong guardrails runs the risk of creating opportunities for abuse. Among those who decide to die via assisted suicide will likely be complicated people with complicated motivations, some of which might not seem reasonable to others. On the other hand, in countries where assisted suicide is illegal, people often find other ways to end their lives. (The leading cause of suicide deaths in the United States is not a new technology like the Sarco pod but a much older one: guns.)
How governments balance the need to protect their citizens’ rights while also safeguarding the most vulnerable among them is a real conundrum. Switzerland found a balance, but the Sarco pod threatened to upset it. Restoring the balance is more than just a major imperative. It’s a matter of great moral significance — and of life and death.
The pod looked like a tanning bed from another planet: a human-sized chamber, white and sparkly purple with a clear glass door, resting on an inclined platform. Previously, it had been on display in public exhibitions, but now it was in Schaffhausen, in a large park in northern Switzerland, near the border with Germany.
A woman stood in front of it, under a dense canopy of trees. She wore a white fleece jacket, dark pants, and flip-flops. It was late September 2024, and the air in this part of the country had become cool.
The woman, a 64-year-old American whose name has not been made public, had come to the Alpine country, to this place of vineyards and rolling meadows and mountain views, to end her life.
It was a private decision that, paradoxically, would have global implications for the debate over end-of-life care and whether people have a right to medically assisted suicide.
For more than 25 years, Switzerland has been a destination for people who want a medically assisted suicide, thanks to the country’s longstanding and liberal law regarding the practice. Each year, the number of people choosing assisted suicide in the country grows; in 2023, that number reached more than 1,200. Most people who end their lives in Switzerland are elderly or have an incurable illness, though a person can sometimes get approval for an assisted suicide under other circumstances. And though the majority who die this way are citizens, Switzerland is one of the few countries that also allows foreigners to travel there for the purpose, a practice critics have derided as “suicide tourism.”
The country’s largest assisted suicide nonprofit, Exit, takes only citizens and permanent residents. But other prominent organizations, including Dignitas and Pegasos, accept foreigners. People who are interested reach out to the groups online and apply for membership, which provides counseling and guidance around end-of-life care. Those seeking a medically assisted death are required to have consultations with a doctor associated with one of the organizations. After determining that the person is eligible, of sound mind, and, when applicable, has considered their full range of treatment options, the doctor writes a prescription for sodium pentobarbital, the same substance used for pet euthanasia and many lethal injection executions in the US, to be used at a later date chosen by the patient.
The doctor is not allowed to administer the medication themselves. That practice is known as euthanasia, which is not legal in the country because it is considered “deliberate killing.” Instead, they provide the medication to the patient, who, in the presence of the doctor or an aide for one of the organizations, either swallows it or takes it with a gastric tube or an intravenous infusion.
The entire process, for foreigners, costs about $11,000 and usually takes a couple of months.
Had the American woman chosen to end her life under the standard Swiss protocol, it probably wouldn’t have been controversial. She reportedly had skull base osteomyelitis, a rare and painful inflammatory condition that is often fatal if untreated. She told the group helping her that her adult children fully supported her decision.
But she wasn’t there to end her life the standard way. Instead, she was about to become the first person to try a controversial new method for suicide, using a technology that would roil public debate over assisted suicide in Switzerland and capture attention around the globe.
She would use the Sarco pod, an invention of Philip Nitschke, a strident right-to-die advocate. Nitschke hopes that the 3-D printed pod, with a name that’s short for sarcophagus, will revolutionize the practice of voluntary assisted death by taking doctors out of the picture.
The Sarco, he has said, doesn’t require a lengthy screening process or thousands of dollars. Rather than relying on sodium pentobarbital, a person who wanted to use the pod could buy nitrogen. They would lie down inside the pod, resting their head on a neck travel pillow. Then, they would close the door and push a button. The chamber would fill with nitrogen gas, and oxygen levels would quickly drop below levels humans need to survive.
As a method of execution in the US, nitrogen hypoxia has been highly controversial. Earlier this year, UN experts raised concerns that the execution of Alabama death row inmate Kenneth Eugene Smith using nitrogen gas could constitute “torture,” and the state is currently being sued by another inmate alleging the practice is cruel and unconstitutional. Right-to-die advocates, though, say that when administered properly, it’s a relatively painless death because people exposed to high levels of nitrogen quickly lose consciousness.
The American woman entered the chamber just before 4 pm, according to Dutch newspaper de Volkskrant, which had a photographer in the woods of Schaffhausen before and after the death to document the scene. To protect against the possibility that they might be accused of foul play, Nitschke and his colleagues also set up two video cameras to record. Then Nitschke went across the border to Germany, possibly to avoid the risk of arrest. The only person who remained with the woman at the scene the entire time was Florian Willet, a colleague of Nitschke’s who co-founded The Last Resort, an organization to promote the Sarco pod’s use in Switzerland.
Seconds after entering the pod, the woman pressed the button to release the gas. Willet waited with her, monitoring her vital signs on an iPad and relaying them to Nitschke over the phone. After confirming her death, Willet called the police — a standard practice after an assisted suicide in Switzerland.
Typically, police examine the scene to verify that there are no signs of foul play.
But this wasn’t a typical death. Police arrested Willet, his attorneys, and the de Volkskrant photographer nearby on suspicion of “inducing and aiding and abetting suicide,” according to Reuters.
More than eight weeks later, Willet remained in jail, with police investigating the woman’s death as a possible “intentional killing.”
And Switzerland, a country that has for decades maintained a public consensus in support of assisted suicide, has been confronted with a series of questions that have implications for one of the most significant moments of every person’s life: To what extent should people have the right to determine when and how they die? What are the moral and philosophical implications for a society that sanctions the practice of medically assisted suicide? How does a nation handle the need for the safety of vulnerable people while also protecting their dignity and individual rights?
Switzerland isn’t the only country that allows assisted suicide. Other nations, including the Netherlands, Belgium, Luxembourg, Colombia, Spain, and Canada, also permit the practice, which some advocates call medical aid in dying (MAID) to differentiate it from the usual connotations of the word “suicide.” In late November, the British Parliament took the first step to pass a bill that would legalize assisted dying for some terminally ill patients.
In some countries, the law goes further than it does in Switzerland, allowing voluntary euthanasia, where doctors can administer lethal doses for patients who can’t or don’t want to do it themselves. Belgium and the Netherlands, for example, allow physician-assisted euthanasia for mental illnesses if a doctor determines that the condition creates unbearable suffering. What constitutes unbearable suffering, though, is inherently subjective and open to interpretation.
The number of deaths via euthanasia in both countries has grown considerably in recent years; the same is true of Canada, which recently passed some of the world’s most liberal euthanasia laws. Critics worry that the easy availability of assisted death creates incentives for people to see it as the only solution to their suffering, even when there might be effective treatments. They also worry about a “slippery slope” where doctor might approve assisted suicide for more and more reasons, ultimately resulting in suicides for non-medical reasons being enabled by law.
The United States does not permit euthanasia, but physician-assisted suicide is legal in 10 states, including California, Oregon, and Washington. According to a Gallup survey earlier this year, 71 percent of Americans believed that a doctor should be able to administer a euthanasia drug if requested by a patient or their family member, and nearly the same amount supported physician-assisted suicide for people with terminal illnesses.
Erika Preisig, a family physician and founder of the organization Lifecircle, which helps foreigners come to Switzerland for assisted suicide and advocates for other countries to legalize it, says the issue is going to become more important as more baby boomers reach the end of their lives.
“They will not let others decide how they have to die. They will decide themselves,” says Preisig, who is a member of that generation. “This will raise the percentage of assisted dying all over.”
Drew Shannon for Vox
But even with widespread support, the practice is still controversial in the US and elsewhere. The American public, despite supporting legalization, is more divided on the morality of doctor-assisted suicide. It’s opposed by the Catholic Church and other Christian organizations, which believe the practice goes against God’s will. Some disability rights advocates have argued fiercely against it, saying that it allows medical professionals to offer disabled people death rather than finding ways to improve their lives. The American College of Physicians (ACP) also opposes medically assisted dying on the grounds that the practice is incompatible with a doctor’s duty as a healer who takes the Hippocratic Oath, promising to do no harm.
“[T]he focus at the end of life should be on efforts to prevent or ease suffering,” the ACP’s president said in 2017. Partly as a result of those disagreements, Americans have different rights regarding assisted suicide depending on which state they live in. That’s led some Americans, including the woman who used the Sarco pod, to come to countries like Switzerland to end their lives.
The birthplace of Calvinism and an intellectual center of the Protestant Reformation, Switzerland has a long history of bucking the dogma of the Catholic Church and charting its own moral and philosophical path. Famously neutral during the World Wars, and now home to world governing bodies like the United Nations and the World Health Organization, the country can appear to be a tightly regulated place like many other Western European countries.
In reality, it’s a society built on compliance with social and cultural norms moreso than government regulations. Political scientists point to it as among the most libertarian societies on earth, and Switzerland is consistently ranked as the number one country in the Human Freedom Index report put out by the Cato Institute, a libertarian think tank.
Assisted suicide is no exception. The practice has been permitted in Switzerland longer than in any other country. In 1942, the government put into effect a statute outlawing abetting assisted suicide for “selfish purposes,” like gaining access to an inheritance, but otherwise, it wasn’t explicitly banned — which meant that, by omission, assisting suicide for non-selfish purposes was technically legal. To this day, the 1942 statute is the only law explicitly referring to assisted suicide. In an email to Vox, the prosecutor in charge of the case confirmed that Willet was arrested under suspicion of breaking this law.
In place of those laws, requirements for obtaining a medically assisted suicide were developed by doctors and codified into guidelines maintained by Switzerland’s medical professional organizations. The regulations are nonbinding, but disobeying them can in theory lead to professional sanctions. In practice, this has meant that the doctors are regulating themselves.
“We have one of the most liberal systems in the world,” Yvonne Gilli, the president of the country’s professional association for doctors, told Vox in an email. For most of the medical community, the desire seems to be to keep it that way. “We would therefore do well to leave doctors in a central role in assisted suicide,” Gilli wrote.
In a small, relatively homogenous nation of just under 10 million people, assisted suicide has never been quite the culture war issue it was in the United States in the 1990s and early 2000s, when Dr. Jack Kevorkian, a right-to-die advocate nicknamed “Dr. Death” by the media, filmed himself performing a voluntary euthanasia and sent the video footage to 60 Minutes, intentionally triggering a trial that would result in his conviction for murder.
In 2011, a referendum that proposed a ban on assisted suicide in Zurich, the country’s most populous canton or state, was rejected with 85 percent of the vote. That high level of public support has allowed assisted suicide organizations to operate with relatively little friction and without much public debate, even as demand increases. According to a long-term study of assisted suicides in the country from 1999-2018, the total number of physician-assisted suicides doubled every five years.
“Suicide assistance has been quite calm. The Swiss assisted suicide organizations were under the radar; there wasn’t much discussion about them,” says Bernhard Rütsche, a professor at the University of Lucerne and an expert on assisted suicide in Switzerland. “They care for their reputation. The whole branch of suicide assistance has been shaken up with this new method, and they don’t like that, quite understandably.”
The intervention of Nitschke and his Sarco pod threatens to upend the status quo.
In 1996, Nitschke became the first doctor in the world to help a terminally ill patient die legally by assisted suicide in Australia. A decade later, he and his partner Fiona Stewart published The Peaceful Pill Handbook, a guide that provides information about methods of assisted suicide and describes the process of obtaining one in Switzerland.
Nitschke, according to Katie Engelhart’s book The Inevitable: Dispatches on the Right to Die, began his work believing that patients with terminal illnesses should have the right to choose an end to their suffering. But as his advocacy deepened, his thinking evolved. Why should doctors like him be the one to make the decisions? Why should doctors get to determine what counts as extraordinary suffering and what doesn’t?
Over time, Nitschke came to believe that the right to die should be entirely in the hands of individuals and not medical professionals. The deeper his advocacy became, the more he clashed with other members of the medical community. He burned his medical license in 2015 after a protracted battle with Australia’s medical board. He also became more critical of mainstream MAID groups that focus only on the sickest patients.
He takes issue with the Swiss system, which he has said is too deferential to doctors and too expensive. “We are convinced that no money should be charged for an assisted death. Especially when you realize that it is already very expensive for foreigners who wish to die to travel to Switzerland,” Nitschke said of his organization, Exit International, in a recent interview. (Exit International, which is not related to the Swiss group Exit, pointed to statements on their website and declined to be interviewed before deadline.)
Nitschke approaches end-of-life issues with the zeal of a libertarian techno-futurist. In interviews, he’s spoken about a future where the Sarco pod’s blueprints are posted online, allowing anyone to 3-D print one anywhere in the world. He has said that AI could replace doctors in assessing whether a person meets the criteria to end their life. “We really want to develop that part of the process so that a person can have their mental capacity assessed by the software, rather than … spending half an hour with a psychiatrist,” Nitschke told Wired.
Nitschke’s unapologetic belief that people should be able to choose how and when they die, combined with his confrontational style, has made him a lightning rod for controversy, leading some of the doctors who support assisted dying to think that he does more harm to their cause than good.
“Nitschke wants to give everybody, without thinking, the possibility to die. For me, this is unethical,” says Preisig, the founder of Lifecircle. “This is very bad for Switzerland. It’s a big problem for us.” Leaders of other assisted suicide organizations have also been critical.
The debate over the Sarco pod has even reached the Swiss government. Nina Fehr Düsel, a member of the Swiss National Council (which is similar to the US Congress), has made a motion for the National Council to discuss assisted suicide in the coming months. She’s also asking her colleagues to consider banning the Sarco pod explicitly.
“I don’t want to overregulate this,” Fehr Düsel, a member of the populist right-wing Swiss People’s Party, which controls the most seats in the federal assembly, tells Vox. She has concerns about the use of nitrogen, which is at this point cheap and easy to obtain in the country. In general, she says, the organizations that are already established in the country should be left alone. “We already have these two longstanding organizations and that is enough,” Fehr Düsel says.
For others, the Sarco pod case has merely exposed the extent to which assisted suicide is operating without clear legal guidelines. “We need some regulation that ensures that autonomy is safeguarded and capacity is properly assessed, and the means for suicide assistance — the instruments and the medications — are safe and comply with human dignity,” says Rütsche, the professor at the University of Lucerne.
According to Rütsche, the government should codify the existing standards doctors have established, with laws around the assessment of someone’s capacity, obligations to provide information and counseling to make sure the decision is well considered, requirements for how the process takes place (including what drugs and devices are allowed and what aren’t), and oversight for the assisted suicide organizations — with the ability to ban a group for flouting the guidelines.
Whether Switzerland moves forward with a new law remains to be seen. But the Sarco pod’s future seems more certain.
Drew Shannon for Vox
Police confiscated the pod at the scene of the woman’s death. In November, Schaffhausen prosecutor Peter Sticher confirmed to Vox in an email that one person remained in police custody regarding the investigation. Willet, according to The Last Resort’s website, has been held in jail for two months.
Holding someone that long on suspicion of abetting a suicide for selfish purposes is highly unusual. But in late October, de Volkskrant, the Dutch paper, reported another reason that may explain Willet’s long detention: According to court records, a forensic doctor told investigators the woman was found with injuries to her neck, raising the possibility that Willet was the subject of an “intentional killing” investigation.
“The allegation of a [killing] is simply not true, and I’d guess everyone involved knows this,” says Andrea Taormina, the lawyer for the photographer who was detained after the woman’s death. “There are no facts that would indicate differently. This is mainly an allegation brought forward simply to raise the stakes in this procedure.”
De Volkskrant, which had access to and reviewed the camera footage, said in their report that nothing on the recording showed Willet opening the pod or doing anything to disturb the woman.
Ultimately, after 70 days in detention, Willet was released in early December.
Exit International and The Last Resort, Nitschke’s organizations, celebrated Willet’s release. “The allegation of intentional homicide was, and remains, absurd,” it said in a statement.
But in response to an email, Sticher told Vox that both investigations remained open. “All persons are still under investigations, for aiding and abetting a suicide for selfish purposes and for intentional homicide,” Sticher wrote. “But we had no more reasons to keep this last person in custody.”
While the drama brought by the Sarco pod’s use is exceptional, the broader debate shouldn’t be.
According to a UN report from 2023, the world population of people over 65 is expected to double, from 761 million in 2021 to 1.6 billion in 2050. In 25 years, people over 65 will make up 1 in 6 people on Earth — part of a global trend toward aging. Thanks to legalization in several countries, many of these people now know that physician-assisted suicide is an option. Assisted suicide remains rare, both globally and in the US. But as more attention is paid to it, the moral, philosophical, and political questions that the case prompted will only become more urgent.
In Switzerland, where assisted suicides are still a relatively small percentage of overall deaths, supporters say it’s important to maintain that right. “Modern medicine is keeping people alive longer and longer. This is why there are more and more very old people, and therefore more and more medical problems towards the end of life,” Marion Schafroth, the president of Exit, said in an email. “Human support for suicide is certainly not morally wrong. It serves the dignity and self-determination and safety of those who wish to die.”
Even if they don’t ultimately choose assisted suicide, says Preisig, the founder of Lifecircle, it’s important for people who are seriously ill to know they have the option. “People are not afraid of death, they’re afraid of unbearable suffering,” she says. “When they know they could [die] if they wanted to, then they lose this fear of unbearable suffering. This is the most important point for me.”
Still, other countries, like Canada, are grappling with serious concerns about whether the criteria for approval is expanding too quickly, enabling or even encouraging people who aren’t suffering to end their lives.
Canada’s Medical Assistance in Dying (MAID) program is a primary example for critics of what can go wrong. When MAID was first legalized in 2016, Canada had strict criteria: It was only to be used to end unbearable suffering in patients whose conditions were advanced and whose impending death was reasonably foreseeable.
In 2021, following a court ruling, the government removed the criteria that a death be reasonably foreseeable. Stories emerged of people who had been approved for euthanasia who didn’t have terminal illnesses. Health care workers have said they’re struggling with the ethical implications arising from people requesting euthanasia not for incurable illnesses but because they’re on government subsidies, were recently widowed, or are dealing with chronic but nonfatal conditions like obesity. And in October, a Canadian committee found that people had received approval for euthanasia for reasons such as social isolation.
Some disability rights groups in Canada are challenging the country’s expanded MAID laws in court. “We are witnessing an alarming trend where people with disabilities are seeking assisted suicide due to social deprivation, poverty, and lack of essential supports,” a leader of the group, Inclusion Canada, said in a statement in September. “This law also sends a devastating message that life with a disability is a fate worse than death, undermining decades of work toward equity and inclusion.”
The controversies around these cases, like the Sarco case, are raising uncomfortable questions for which there might not be easy answers. A legalized assisted suicide program without strong guardrails runs the risk of creating opportunities for abuse. Among those who decide to die via assisted suicide will likely be complicated people with complicated motivations, some of which might not seem reasonable to others. On the other hand, in countries where assisted suicide is illegal, people often find other ways to end their lives. (The leading cause of suicide deaths in the United States is not a new technology like the Sarco pod but a much older one: guns.)
How governments balance the need to protect their citizens’ rights while also safeguarding the most vulnerable among them is a real conundrum. Switzerland found a balance, but the Sarco pod threatened to upset it. Restoring the balance is more than just a major imperative. It’s a matter of great moral significance — and of life and death.
Marin Cogan is a senior correspondent at Vox. She writes features on a wide range of subjects, including traffic safety, gun violence, and the legal system. Prior to Vox, she worked as a writer for New York magazine, GQ, ESPN the Magazine, and other publications.
Haitian president François Duvalier (a.k.a. Papa Doc) at his coronation as president for life, Port-au-Prince, Haiti 1963. © wikimedia commons
