Known historically for its independence and individualism, Switzerland is now setting the pace for the practice of assisted suicide on a wider scale even than the Netherlands.

Today there are no less than four ‘right-to-die’ organizations in a country with a population of seven million. Two of them offer help with hastened death to both terminally ill and chronically ill, be they resident or foreigner. One group will even visit a dying patient in another country if there is no alternative.

Switzerland has not had a law forbidding assisted suicide since the criminal code was revised in l937. The relevant law para.155 -- is interpreted to mean that anybody - doctor, nurse, family or friend - can assist a suicide of a physically sick person provided it is done for altruistic reasons. If assistance is given out of evil motives, or financial gain, then it is a crime -- but there are no known cases of prosecution. The law says nothing about visitors.

Estimates in recent years have put the amount of hastened deaths at between one and 200 a year. No official statistics kept because it is not an offense.

But such is the growing worldwide interest in assisted suicide that what was ten years ago a quiet, compassionate, national practice in Switzerland has recently spilled over into an international context. Because most nations (except the Netherlands and one American state, Oregon) will not legalize assisted suicide, desperate persons who believe in the freedom to die at a time of their choosing are looking to Switzerland.

(Clarification of terms: assisted suicide is not euthanasia. Assisted suicide means helping the patient find the lethal drugs, giving advice and moral support, but leaving the patient to decide whether to ingest the potion. Some call it ‘assisted suicide up to the final, self-release stage.’ Euthanasia is a doctor giving a lethal injection by request. Only the Netherlands permits both procedures, under strict guidelines.)

Neither the Netherlands nor Oregon will accept non-residents for help in dying -- the Dutch require that the physician has known the patient for several years, while Oregon law has a ‘residents only’ provision.

The more flexible law in Switzerland, together with four proactive organizations, means that interest has mounted from persons with intolerable physical health problems in surrounding countries which will not change their prohibition. Austria, Germany, France and Spain are affected.

My inquiries into the situation indicate this position currently:

EXIT- German speaking. With 50,000 members, this powerful Zurich group is the most active in helping Swiss citizens to die in appropriate cases. It does not help foreigners. The pentobarbital is obtained from the patient’s doctor, but the EXIT helper usually makes all the arrangements, even to handing over the lethal cocktail, but leaving just before death. EXIT always informs the local police of what happened, they check it out, and the death is officially recorded as suicide.

This organization gets just over 300 calls a year from people wanting help to die, with 120 actually getting assistance in an average year. Swiss professional medical groups as a policy discourage doctors engaging in assisted suicide, but some do when circumstances justify it, particularly when an intravenous injection is required.

Persons with mental health problems are not helped. Any doctor who writes a lethal prescription – almost always ten grams of pentobarbital -- for no acceptable reason is unlikely to be prosecuted but will lose his or her medical license.

Contact:
EXIT Switzerland. EXIT/Vereinigung für humanes Sterben
(German-speaking), Feldeggstraase 13, P.O. Box 309, CH-8034
Zurich/Switzerland.
E-mail: freitodbegleitung@exit.ch
Web URL: www.exit.ch

NO PHYSICIANS EXIT- International is a breakaway from the Zurich organization. It is a small but wide-ranging group run by an elderly doctor of philosophy, the Rev. Rolf Sigg. Small though it is, the group is apparently well funded and willing to travel throughout Europe to help people die, though for the time being only German-speaking persons are assisted because of language problems. He claims to have helped in his lifetime more than 300 people die so far -- double Dr. Jack Kevorkian's total. (Kevorkian is serving life imprisonment for murder in what was, ethically, a justified voluntary euthanasia.)

Dr. Sigg has been particularly active in Germany where the strange situation exists that while assisted suicide has not been a crime for hundreds of years, hardly any doctors will practice it because of the depth of shame in the country over the Nazi so-called Euthanasia T-4 program’ during World War Two. Almost 100,000 Germans who were physically or mentally handicapped were systematically murdered in a frenzy of Aryan race-cleansing.

Law enforcement authorities in Germany have several times pressed charges against Dr. Sigg for bringing pentobarbital into the country, secured convictions, but on appeal they were dismissed. Appeal judges warned him not to continue importing narcotics but at the same time praised his humanitarianism. The appeal court also re-affirmed that assisted suicide is not a crime in Germany.

Lacking narcotics, Dr. Sigg nowadays mostly uses the plastic bag technique if he cannot persuade the patient’s own doctor to prescribe barbiturates. He is opposed to doctors carrying out any form of euthanasia, believing that the task is more suited to specially trained operatives.

Contact:
EXIT.-International.
Postfach 605, CH-3000, Bern 9. Switzerland.

VISITORS ACCEPTED

DIGNITAS was formed three years ago with a motto of "To Live With Dignity - To Die With Dignity." It is headed by attorney Ludwig A. Minelli in Forch, Switzerland, and has helped about 30 people to die so far. It has a cautious and law-abiding approach.

Minelli says in an email to me: "DIGNITAS does help also foreigners [who come to this country]. They must first be members for an annual fee of 25 Swiss francs. No other fees are charged. The member must themselves get a prescription from a Swiss physician for the lethal dose of pentobarbital after examination of physical symptoms and case documentation. The case must fit Swiss law."

DIGNITAS issues its brochures in German, French, Italian, and soon English.

Contact:
DIGNITAS.- Postfach 9, CH-8127, Forch, Switzerland.
Email: dignitas@dignitas.ch.
Web site: http://www.dignitas.ch/

FRENCH RESERVE

In a nation where at least three separate languages are spoken, the most reserved about assisted dying are the French-speakers. (But all groups like the name Exit’ causing no small confusion to outsiders.) The small but persistent group EXIT A.D.M.D. Suisse romande, based in Geneva, distributes advice but does not actively help people to die.

Contact:
Exit/A D M D (Suisse Romande) C.P. 110, CH-1211, Geneva 17, Switzerland.
Email: exit@freemail.ch
Web site: www.exit-geneve.ch

GERMAN SPILLOVER

The fact that EXIT-International travels around Germany helping people to die, and that DIGNITAS will accept foreigners who qualify, has given the 21-year-old Augburg-based group, Deutsche Gesellschaft fur Humanes Sterben (DGHS), a great deal to think about. Some of its members are pressing for it to be more supportive of dying members, such as Caring Friends does for Hemlock members in the USA.

Dr. Kurt Schobert, the group’s secretary, told my by letter: "There is massive frustration in our society and the Western world who want law-reform but they do not get it."

Schobert feels that, while there is no direct prohibition ofassisted suicide, parts of the German penal code (323c) could be used to prosecute people because they failed to help the person live. There have been prosecutions in Germany of people who failed to call an ambulance speedily enough to resussicate a victim who had expressed a wish not to live anyway.

Says Schobert: "The best we can do is to collect and distribute information about how we are able to help people within the law, and thus give people the power to do it themselves."

Contact:
DGHS. Postfach 11 05 29. 8630 Augsburg, Germany.
Email: info@dghs.de
Web site: www.dghs.de

The fact that voluntary euthanasia and assisted suicide will become fully legal in the Netherlands in 2002 has sparked off virulent opposition from Roman Catholic, Orthodox and Protestant churches in Europe and Russia. These powerful churches are organizing to try to stop any similar legislation in their own countries.

According to polls, 75 percent of Germans support law reform on assisted suicide, while 60 percent say the church has no right to intervene in questions of dying.

Read more on the Swiss situation at: http://www.finalexit.org/pract-swiss.html

Derek Humphry, author of Final Exit’, is president of the Euthanasia Research & Guidance Organization (ERGO)
derekhumphry@starband.net

(2 August 2001)

A Report by Professor Meinrad Schaer, MD, President of "EXIT', Society for Human Dying, Switzerland

In my lecture given at the 11th World Conference of Right to Die Societies in Melbourne (l996), I reported on the legality and practice of assisted suicide in Switzerland. Today, I would like to present some practical case reports illustrating the procedure.

While the USA struggles with controversy regarding the legality of assisted suicide, the Swiss legal system has condoned the practice for sixty years. In contrast to practices in Holland, Australia and the various US proposals where assisted suicide is limited to physician-assisted suicide, Swiss law permits and EXIT practices aid to the dying by lay persons.

Although Swiss law permits physicians and non-medical persons to assist suicides, the Swiss Academy of Medical Sciences, like many medical organisations, including the American Medical Association, opposes doctors helping patients to die. Swiss laws stipulate that persons who assist a suicide do so for humane reasons with no chance of personal gain. EXIT requires that the applicant be at least eighteen years old, a Swiss resident, mentally competent and suffering from intolerable health problems. He, or she, must personally apply for the service and convince EXIT that there is no coercion or third party influence involved in the decision.

An EXIT physician considers the application and decides whether or not assistance can be offered. In doubtful cases, a team composed of a lawyer, psychiatrist and a physician will jointly make the decision.

The procedure of assisted suicide is as follows:

• An EXIT team member provides an anti-emetic (two DramamineQ tablets) to the patient and half an hour later, 10 g.of sodium pentobarbitone is given. Within five minutes, the patient falls into a deep sleep and within two hours, with few exceptions, will die peacefully. The team member stays with the patient unfit death occurs and there is always a witness present, usually a close relative.

• Immediately after death has occurred, the police are informed and they notify the appropriate officials, prosecution attorney, coroner, criminologist et al. who visit the scene to establish whether or not laws have been violated. Since EXIT was founded in 1982, no collaborator has ever been prosecuted for his participation in assisted suicide.

Assistance offered by EXIT to its members in 1996

Some case reports from 1997

Apart from a 'sciatic hernia'-operation, Rubin T. had never been ill before. About five years ago, however, he began to suffer paralysis in his feet. Slowly the paralysis spread through the lower extremities and after two years Rubin was entirely dependent on a wheel-chair. Later he became partially paralysed in the chest area and in his arms and finally he had great difficulties breathing and swallowing. The patient knew his condition was irreversible and would culminate in a respiratory paralysis. He was also aware that he would be totally dependent on other people's care for the rest of his life. Therefore, he decided to contact EXIT.

When the suicide assistant first visited Rubin's family, the family members were unsure how they should react. Rubin T. was complaining about increasing pain and his wife was afraid she soon wouldn't be able to look after him anymore as she, herself, was suffering from cancer metastases and was expected to undergo operation. The patient, on the other hand, refused to go to a nursing home. Accepting this wish was one of the major aspects in the family s decision making and finally they acceded to Rubin's decision to commit suicide.

On the day of his death we were warmly received by the united family. Everybody, wife, son, daughter and son-in-law, agreed that assisted suicide was the best solution in this hopeless situation. Their family doctor, who had witnessed Rubin's decline over the years also felt that this was the best decision in the circumstances.

After a heartbreaking farewell to his family Rubin T. drank the barbiturate, which had been dissolved in a deciliter of water. During the ensuing few minutes they wished each other well and soon thereafter, Mr. T. Iost consiousness, breathing deeply and with a contented smile on this face. Ten minutes later he stopped breathing and shortly afterwards, no pulse could be discerned. The family stayed with Rubin for a short while praying and expressing hope of a reunion in heaven.

Because it is classified as an exceptional death, each suicide must be investigated by the police and a coroner. Rubin lived in an isolated, sparsely populated, mountainous area of Switzerland and suicides are comparatively rare in this region. Th police officers notified, were uncertain as to how they should proceed. They recorded our statements, called for re-enforcement and finally for the examining magistrate. The widow was spared long questioning and others present were questioned in a friendly manner. Then peace returned to the deathbed and we left. Everyone present thanked us for our assistance. Father McDonald still keeps in contact with the bereaved family.

An EXIT suicide assisant told me about a critically ill woman who had asked her for help. The patient Wily B. was suffering from cancer of the pancreas which had led to an obstruction of the bowels. She could take neither liquids nor solids and the only way to administer the barbiturate was via intravenous infusion. Her family doctor agreed with this decision and prepared the saline infusion. Then he said goodbye to the patient and her daughter.

Taking the barbiturate intravenously is not the usual method of assisted suicide. Therefore two EXIT representatives, a physician and a lay person together with the patient's daughter were present when the infusion was administered. Wily B. was instructed how to use the three way switch controlling the infusion. After she had closed it, the barbiturate was injected into the infusion and within two minutes of opening the switch herself she fell into a deep sleep yawning peacefully. Seven minutes later breathing and pulse stopped.

Neither the coroner nor the examining magistrate showed any concem about the uncommon method of assisted suicide used in this special case. The bereaved daughter was relieved that her mother was spared any further suffering and was also glad that Wily B. could depart in dignity.

Linda B., a widow, had been living alone for many years. She was financially secure and lived in a five bedroom villa at the lake of Zurich. In the course of the past three decades she had undergone several operations, radiotherapies and chemotherapies. Nevertheless she had kept her happy disposition and had always accepted her fate. Only lately, as a result of serious complications with her colon cancer, she began to take stock of her life. An almost complete obstruction of the bowels made it impossible for her to take any solid food. She also had to deal with faecal vomitus.

At first her family doctor disapproved of the idea of assisted suicide. Yet Linda B. came to an agreement with him and contacted EXIT requesting assistance towards a hastened dignified death.

Linda wasn't able to take the barbiturate orally because of her bowel obstruction so EXIT contacted her doctor and asked him to prepare an intravenous saline infusion, to which he agreed. The EXIT suicide assistant instructed the patient how to use the three way switch and then injected a lethal dose of the barbiturate into the infusion. He asked the moribund patient to open the switch when she was ready. Surrounded by mourning family members she quietly fell into her eternal sleep.

Shortly after her death, which occurred within less than fifteen minutes, an uncommonly large police contingent arrived with detectives, examining magistrates, coroners, etc. The district medical officer showed some consternation regarding the administration route of the barbiturate. However, since the patient had switched on the infusion herself and since this had been witnessed by 6 family members as well as two EXIT representatives, the magistrate didn't take any further steps. The mourners were obviously relieved. Together with the EXIT-representatives they left the house of their mother and grandmother leaving a light in the bedroom of their beloved dead.

Martha H.'s husband consulted me personally seeking our assistance. His wife's health had worsened in the course of the preceeding weeks. Martha H. had been suffering from the neuromuscular illness ALS for two years and at the time of her husbands call she could utter only unarticulate sounds. Furthermore, she had problems swallowing. After talking to her doctor on the phone I went to see the patient right away. The attending physician had confirmed Martha H.'s desperate state of health and the rapid progression of this genetically caused illness for which there is no cure.

On my visit, Mrs. M.H. was sitting in her wheelchair. Her legs and arms were paralyzed and she could move her right arm only. Nevertheless she seemed pleased to see me and expressed her joy with lively movements of her eyes and by nodding her head. She understood everything but could only answer by scribbling big, shaky letters. To find out if the patient was still able to drink and swallow I handed her a glass of water. Promptly she choked and coughed out most of the liquid. That same day, I contacted her doctor again to discuss further procedures. As the patient was already being fed through a tube, this method was certainly the best. The remnants of strength and agility left in the patient's arm were considered sufficient for her to take the barbiturate herself.

A few days later, on the date chosen personally by Mrs. M.H., the suicide assistance took place. Her husband, two sons with their wives, and 1, as a suicide assistant of EXIT, were present. Five minutes after taking the barbiturate the patient fell into a deep sleep. Ten minutes later, her breathing, and shortly afterwards, her heart stopped. Mrs. M.H. died peacefully in the arms of her husband. The relatives asked me to remain seated quietly for a futher ten minutes to respect the dead.

Afterwards, as required by law, I called the police. They must be informed of every 'uncommon' death and I was rather surprised when only the district medical officer and a police official arrived. Later I was told that the family doctor had already informed the responsible authorities about the planned suicide. The patient's wish had been fulfilled: She had died in peace and tranquility surrounded by her closest relatives.

A leading doctor of an AlDS-hospice drew my attention to a patient who was in a deplorable state of health. On the same day I visited the critically ill man and had a private talk with him.

Mr. C. was hemiplegic and had difficulties speaking. He understood everything and made it absolutely clear he didn't want any specific therapy apart from palliative treatment. Mr. C. had written to his family doctor and his two brothers, who lived in the western part of Switzerland, informing them about his decision to commit suicide with the help of EXIT. Everyone, even the doctor in charge of the AIDS - hospice regarded the suicide as the only option to end his unbearable suffering. (The diagnosis of the AIDS specialist was: AIDS Illc).

A few days after my first visit the patient was brought, in a wheelchair, to his apartment where the euthanasia took place in the presence of his two brothers. (Two minutes after taking the barbiturate Mr. C. fell asleep and after another eight minutes his breathing and heart stopped).

At the end of May 1997 Mrs. G. asked EXIT for a meeting with a suicide assistant. She was suffering steadily increasing difficulties in breathing caused by the amputation of both breasts. They had Upunctured her several times", she told the E)CIT representative ~and each time had sucked out between half and one litre of a bloody liquid. Lately she had suffered unbearable pains which had only been brought under control with high doses of MST (a morphine derived drug which can be taken orally). Such a high dosage of MST can lead to interrupted breathing especially if the patient already suffers from pleural effusions, which also cause breathing difficulties.

The patient looked happy and regarded her approaching death with composure. She was, she maintained, a 'converted Buddhist'. Her 80 year old mother was looking after her.

To avoid vomiting Mrs. G. was given two tablets of Dramamine. After half an hour she took 1Og of a strong barbiturate, which was dissolved in a deciliter of water. The solution is bitter but no one, to date, has refused the solution on grounds of the bitter taste. Five minutes after taking the barbiturate the patient fell asleep peacefully. Ten minutes later her breathing stopped and soon thereafter her heart stopped. The elderly mother was grateful, because her daughter had been spared a horrible death by suffocation.

• A: metastasing breast cancer
• B: Endangitis obliterans (smoker's)

Her husband, B, was suffering from a painful circulatory disturbance in his legs caused by excessive smoking. Their family doctor confirmed the diagnoses and the hopeless prognoses. He refused, however, to prescribe two fatal doses of a potent barbiturate.

Two suicide assistants of EXIT travelled to the Ticino after the manager had ensured that all requirements for assisted suicide had been satisfied. There they were to assist the couple in their joint suicide. At first, Giula and B lay in separate rooms as they wished to speak privately to their respective suicide assistants. Thereafter they lay down together to pass away hand in hand. Both were full of praise for the way EXIT had assisted them during the last hours prior to death. Their only daughter said goodbye to her parents and they died peacefully, after taking the barbiturate, within 10 and 20 minutes respectively.

As suicide is relatively rare in Ticino and because the police were unsure how to proceed, the examining magistrate requested a coroners report which proved satisfactory.

In the fall of 1993, Samuel B., an internationally famous concert pianist, first felt his legs become limp. Within a short period of time he was partly paralyzed. He consulted a neurologist who examined him with electromyelography and provided Samuel B. with a diagnosis of amyotrophic lateral sclerosis (ALS). This illness of the nervous system usually follows a chronic progressive course and afler a few years the patient generally dies of respiratory paralysis. Two years later, Samuel B's illness had progressed to the extent that the patient's legs were totally paralyzed, which meant that he required a wheelchair. Increasingly, the muscles of his midriff and back became paralyzed. The patient was suffering unbearable pain. Occasionally, especially at night, he had difficulty breathing. His pain could not be relieved by an opiate as he was already suffering from respiratory depression.

In January 1997 Mr. B. called EXIT and asked for immediate help. His condition had significantly deteriorated. Visiting the patient, it was obvious that he had difficulties not just with breathing but also with swallowing. We made an appointment. Samuel B. had to sort out some family affairs before he was ready to die.

A few days later the 'assistance' (euthanasia) took place with an EXIT doctor, just as the patient had requested. Seven minutes afler taking the barbiturate, Samuel B. died in the arms of his wife. Every one present was relieved that he had been spared weeks of suffering, breathing difficulties and intolerable pain.

Mr. and Mrs. H. called to my office. Mr. Jakob H. was limping and his wife had to assist him when he was walking. He wanted to die with the help of EXIT as soon as possible because he could hardly bear the pain in his leg. His pain was caused by a circulatory disturbance and Mr. H. refused to have his leg amputated, a step which sooner or later would have been inevitable. At night he slept for one hour at most and then only while sitting on a chair. Some of his toes were already necrotic and on his right ankle he showed me an open, foul-smelling growth.

Patient H. had been a passionate smoker for decades. Even when his family doctor strongly advised him to give up smoking he paid no attention. Nothing could keep him from indulging in this passion.

The diagnosis of endangitis obliterans had been confirmed radiologically and angiologically.

The assisted suicide was arranged for May 22nd. The 'playboy' Mr. H. received a suicide assistant and myself with extreme friendliness, even somewhat euphorically, while his wife appeared rather reserved. Mr. H. entertained everyone present (his wife, son, brother, a couple they were friendly with, the suicide assistant, who was relatively inexperienced at that time and myself) to a goodbye party at his home bar.

After taking an 'antiemetic' the patient's last wish was to smoke a final cigarette. Fifteen minutes after taking the barbiturate, J.H. died peacefully among his friends and family of a respiratory and cardiac arrest.

On June 11th the genera! practitioner and former student of mine, Dr. Werner R wrote to me about his cancer patient Anna B. who had no hope of cure or respite and who was suffering from severe and painful complications of her condition.

The patient Anna B. was suffering from metastases of an epithelioma of the vulva (cancer of the greater labia). Three years before the labia had been operatively removed and at the time of his letter, metastases had appeared in the Iymphatic gland and the ribs. There was no hope of cure or recovery for the patient. Mrs. B. declined any form of further therapy such as surgery, radiotherapy, or chemotherapy.

Her family doctor came to meet me personally at the train station of the famous winter health resort and brought me to the restaurant and hotel, that had previously been run by Mrs. Anna B. Both her sons received us warmly. The emaciated patient was sitting crouched down in the background. Her mind was calmly set on her immediate death and she saw this option as the only way to find relief from her infinite suffering.

Mrs. B. fell into a peaceful sleep within a few minutes of taking the barbiturate and fifteen minutes later her breathing and pulse stopped. Everyone present expressed relief especially her two sons who prayed at their mother's deathbed.

The police were called and they themselves mobilised the responsible medical officer, i. e. the coroner. The coroner instructed the GP by phone to release the body for burial without any post mortem examination.

Peter McG.'s family doctor drew my attention to the patient's unbearable suffering. He asked me to get in contact with Peter as soon as possible.

In an old wooden house, I found Peter in a small, musty, living room, surrounded by countless books. He was suffering acute pains that radiated from his spine into the back and down the legs. We didn't talk about his illness and his hopeless future. (I knew enough about that from his doctor.) Instead we discussed books, mainly those dating from before World War II. Peter McG. wasn't only an antiquarian but also a successful author. Before I left he told me he was determined to put an end to his unbearable life. If EXIT didn't help him he would know what he had to do.

Two months after this conversation Peter McG. called me up again. His condition had worsened. He wasn't able to sleep even with large dosages of morphine. However, he wanted to finish a final piece of work before putting an end to his Iife. This decision was clearly stated to his family doctor on several occasions. The doctor himself sympathized with him knowing about the patient's intolerable situation and hopeless prognosis.

Surrounded by his family, a son, a daughter and other relatives, Peter McG. took the deadly dosage of the barbiturate. The family doctor and a suicide assistant were also present. Two minutes after taking the drug, Peter fell into a deep sleep. Soon afterwards his heart stopped for an instant and ten minutes later he died. Everyone present heaved a sigh of relief and were glad, that Peter McG. could die in peace and dignity.

Since May 1996 Mr. Werner B. had been suffering undefinable pains in his stomach. On several occasions he visited his doctor and was examined by gastroscopy and ultr~ound but nothing was found and he was regarded a malingerer! In the fall of 1996, Mr. B. collapsed while on holiday in Spain and had to return to Switzerland ahead of schedule. He went to his family doctor suffering unbearable pain, a distended abdomen and continual constipation. Although the patient had lost seven kilos weight, his doctor wasn't at all alarmed.

At the end of 1996 Mr. H. was hospitalized as an emergency. The surgeon, a Dr. W., found an inoperable colon tumour. The patient could only be treated palliatively, via an 'anus praeter' (colostomy).

On my first visit Mr. B. showed great relief about my assistance but was very concerned about the fact that he soon would not be able to swallow anymore.

We arranged for the euthanasia to take place two days later. The patient was still very weak but was able to drink through a straw. Half an hour after taking two tablets of Dramamine he drank a solution of 1Og of barbiturate. Sobbing and crying, his relatives said goodbye to him and soon afterwards he fell into a deep sleep which changed to a coma-like state and then to death.

I was surprised by the fact that only the examining magistrate and a police officer arrived at deceased man's appartment and that they didn't insist on any formalities.

The examining magistrate respected the wishes of the relatives and allowed the body to be returned to the bereaved family after the obligatory coroner's examination.

The examining magistrate gave me lift to the next train station where he thanked me for the exemplary collaboration.

Since 1995 Mrs. R. had been treated by physicians and in hospitals. The illness began with a growth on her arm but the primary focus could not be established. In the course of three years multiple metastases appeared on the skeleton, in the lungs and on the skin.

The patient suffered greatly and was nursed in a clinic where she refused to take any further treatment. The senior consultant of the clinic brought her case to our attention. On my first visit I met an emaciated woman who had difficulty breathing despite the provision of an additional oxygen supply. Two days later, accompanied by her lawyer, she was taken to her sister's house by ambulance. She received a constant supply of oxygen from hospital personnel during the journey.

The patient was so weak that she fell asleep while drinking the barbiturate and after 12 minutes she was already dead. Half an hour later the police, the district medical officer and the district attorney arrived. We had phoned them after Mrs. R.'s death. They did not insist on a coroner's report and allowed the body to be buried.

Meinrad Schaer -- bio:

A professor of social and preventive medicine at the University of Z|rich for over 20 years, and former Vice-Director of the Swiss Federal Office of Public Health. One of the founders of EXIT - the Swiss Association for Human Dying - and its president for many years. Dr.Schaer died in 2007.

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