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the suicide tourist
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Interview: Ludwig Minelli

“Seventy percent of our members which have got provisional green light do never call again. … We do lose more members by natural deaths within a year than we lose by assisted suicide.”
minelli

A former journalist and human rights lawyer, Minelli founded Dignitas in Zurich in 1998. Switzerland is the only country that allows foreigners to legally commit assisted suicide and Dignitas is the only organization in Switzerland that will help foreigners. This is the edited transcript of an interview conducted on Jan. 22, 2006.

Why do you believe in assisted suicide?

I don't believe. I know it, because there are opinion polls showing that 75 to 85 percent of the population do want to have such a possibility if it should be needed.

[Were there] any bad death experiences in your life?

I have been present when my grandmother, mother of my mother, has been very ill, and I have seen when the physician has visited her and she had asked, "Couldn't you give me something so that it would go a little bit quicker?" Then the physician said, "I'm not allowed to, but I will do nothing to make sure that it goes slower."

Did that affect you?

I just noticed it. I think personally that we are autonomous beings which can reflect, and therefore we should be able to say, "Now I have enough, and I want to go." ...

Why open Dignitas to non-Swiss people?

When we had this question, first I reflected. ... On the other side of the [border] is the German town Konstanz. I said to [myself], what is the difference between breast cancer with metastasis in [Switzerland] and one in Konstanz? Several hundred meters. Should this difference be decisive to [say] yes to the person who lives in [Switzerland] and to say no to the person who lives in Konstanz? Therefore I have decided we will accept members in our association also [from] outside of Switzerland. ...

What is Swiss suicide law?

We have just the Section 115 in the criminal code saying that if somebody is abetting and helping a suicide in a selfish manner, then he can be jailed up to five years. So that means that if you are helping and abetting without selfish motives, this is quite legal.

[What are] selfish motives?

The government told the Parliament in 1918, when the government has the proposal of this law, that if somebody has to pay for another person and would say to this person, "You commit suicide so I will not have to pay for you," this would be a selfish motive.

If for profit it would be illegal.

I could say if somebody would make it for normal profit, it would not be illegal. Selfish is something qualified. If you would take a lot of money for this service, then it might be selfish. But if somebody would do it for normal profit, it would even still be legal.

But Dignitas is not working for profit. We are an association, and the association does not make profit. If we make profit, we will take this profit in order to have a higher quality of our services and especially in order to help with suicide prevention, because the real problem in society is not the case that people are asking to have the freedom to go. The real problem is the suicidal problem in our society and that we have huge numbers of suicides and 50 times higher numbers of suicide attempts, and nobody is looking at that. We take that for usual. I think this shouldn't be.

What is suicide prevention?

I think today suicide prevention starts with the starting point [that] suicide should not happen. But we all know that suicide happens. When you are saying that suicide should not happen, you make a taboo of suicide.

So somebody who has suicidal ideas has no possibility to speak to other persons for fear to lose his face. If he would speak to a doctor, he has even the fear to lose the freedom.

So we should change the starting point of suicide prevention, saying suicide is a marvelous possibility for a human being to withdraw themselves from a situation which is unbearable.

But normally somebody who is in this situation has no means to control the situation. ... He needs advice. So therefore we should say, "Together is the possibility to make suicide." We should say, "You should not start the long trip without consulting the travel agency, and you should not start a long trip without having said goodbye to your family and to your friends."

If you do, on the other hand, make information campaigns about no longer properly working suicide methods and about the risks of still working suicide methods, we would have a much better suicide prevention than we have today. ...

[Are there] any guidelines or regulations in Swiss law?

... No, the law does not deal with assisted suicide. It just says when assisted suicide is a crime and nothing else. ...

We have one condition, of course, because if you want to help with a suicide, the person who wants to make suicide must be able to take decisions. See, she should have capacity of discernment, and this is an absolute condition. If somebody is asking us which does not have this capacity, we cannot help, because then the notion of suicide is not properly fulfilled.

[Some people say] suicide is an act of insanity.

That is their opinion which has no grounds, because you must make differences between suicides and suicides. If a suicide is made out of a situation without appropriate reflection, then it may be that this person has been insane. This happens, of course. But assisted suicide with Dignitas will never be an action of an insane person, because when we may help, we can help only if this person has capacity of discernment in the view of their own death.

What if someone is just depressed?

If a depression is lasting for 10, 15 years, and if multiple therapies did not help, and if this person says, "I have really enough, and I do not want to live on for another 10 years with depression," this is quite reasonable and understandable. If somebody ... has lost the husband, she is in acute depression, here I think first should be measures of therapy. Normally this is a situation which can be healed. But if such a situation is lasting for years and [is] therapy-resistant, then I think there is no objection to an assisted suicide.

How often do you refuse to help?

We do normally never say no. We say perhaps, because if a situation of a person is she is mentally ill and she is suicidal, ... just now we have no physician willing to write prescriptions for mentally ill persons, because the authorities of the state controlling the physicians have said that if they will do so, their [certification] would be in danger. ... I think we should have the right to access to the medicament also for mentally ill persons. ...

You believe in assisted suicide for mentally ill?

On the condition that there is capacity of discernment, because if somebody, for instance, is schizophrenic, when he is in attack, then he has no capacity for discernment. But they have the so-called lucid intervals. If they are in a lucid interval, they have capacity of discernment, of course. If somebody is coming and tells us, "I have enough of this awful life, and I would like to go now," we should have the opportunity to help him.

What is the procedure at Dignitas?

The first step is to become a member of Dignitas, then to send an application in order to prepare an assisted suicide. This application should tell us the view of the member, tell us why the member wants to go this way. Then should be added medical documents, medical reports, with diagnosis, with therapists, so that our physician has an overview of the situation of this person. We also call for a CV in order to know what is the family, what this person has done in the life and so on. ...

When we have those documents, we send them to one of our physicians and ask him, "Would you be ready to write a prescription for this person?" Then he may answer yes, perhaps, or no. Perhaps then he will say what he needs further to know in order to make a decision. If he says no, we will look [at] whether he will find another physician who would be in favor of this person. If the physician has said, "Yes, I am ready to write the prescription," we tell our member that the member has now the provisional green light, provisional because definitely green light will be given after the member has seen the doctor.

They're green-lit after examination of their papers by a doctor. Then what?

Seventy percent of our members which have got provisional green light do never call again. It's very interesting.

They are just looking in order to have a choice, to make a choice, because normally they are in a terrible dilemma. ... Would I have to go through the whole illness until the so-called natural death, with all the pains, with all the difficulties, or must I make a very risky suicide attempt? When we are getting the provisional green light, this is a sort of opening an emergency exit. So they know, "I could go through this emergency exit if really I am in difficulties," and this is calming them. ...

Seventy percent never come to Zurich?

Not only never come to Zurich, never call again. We never hear from them. Then we get the invoice for the membership fee for the next year, and then they will pay the membership fee, but they will never call again. It's very, very interesting.

Thirty percent will call again?

From the rest of 30 percent, only a part will come to Zurich. We do lose more members by natural deaths within a year than we lose by assisted suicide.

Sometimes natural deaths will occur very soon after they have got the provisional green light. This shows that they have been in a high tension, and when this tension has gone, they can leave.

[What happens] after the green light is given?

When a person calls and says that the time has come in order to come to Zurich, then we are looking for an appointment with the doctor. We make the necessary arrangements here, and when the person arrives, sometimes the doctor will be here in my living room, together with our member. Also with relatives, because we always tell: "Bring your relatives with you. They should be with you until your last second."

Then the doctor has a discussion with the member, and after that he makes the final decision. He writes the prescription. Afterwards the member will go to our apartment in Zurich. There will take place the accompaniment.

The accompaniment?

In our apartment is one member of our accompaniment team. This escort will speak, will discuss again with our member. We always tell the member: "The fact that you have come ... does not mean that you have said A and you are now forced to say B. You are completely free to go back to your home if you want, and we will be glad if you would do so." But normally [that's] when we get heavy protests: "Oh, no. I am so happy that I am now here, that I can go easily and peaceful."

Then the escort prepares a medicine which is preventing vomiting. Half an hour later the person is prepared, and then at any time [the person can] drink the little potion of sodium pentobarbital in a glass of water. Two to five minutes later the person will fall asleep and then will fall in a very deep coma, and then after some time, the breathing will be stopped, and this induces death.

What happens next?

After the member has died, our escort phones to the police and tells the police that they think we have had an assisted suicide. Then will arrive a police agent, police officer, public prosecutor and a physician from the Institute for Legal Medicine of the University of Zurich. They will make an investigation in order to clear whether there has been a crime or a suicide. The investigation always ends with the [finding] that there has been a suicide. ...

The police are there to clear murder charges?

It is correct that this investigation has to clear whether there is a murder, whether there is a crime or not. Within these seven and a half years of activity at Dignitas, in every single case, the final issue has been assisted suicide and nothing else.

You make a video prior to death. Why?

We have begun to make a videotape of this short part of time when the member is administering the little medicine in order to have evidence for the police that the last act in the life of this person has been fulfilled by the person themselves. This does ease their work, so they will not have to make interviews with all the relatives in order to establish that no third person has made an action on that.

Are you present at time of death?

I am never present at assisted suicide because I do not mix the functions. I am the director of Dignitas. I have to choose to give instructions to my collaborators, and I have to control them, and so I cannot mix myself in the functions.

Do you meet members?

Yes. If they come here at my house to see the doctor here, I am also speaking with them. Sometimes also we'll bring them to the apartment in Zurich, but always I'm leaving the apartment before the actions of our escort begins.

The escort?

These are collaborators which know how to administer the medicines, because we have also members which are not able to swallow. So sometimes they have a gastric tube, and sometimes it's needed profusion in order to bring the medicine into the circulation of the blood. There we need a person who is instructed how to proceed.

They have the duty to look that no risks will occur, because also with sodium pentobarbital there are risks, and therefore they have to pay attention that no risks will turn into a bad issue.

Risks?

For instance, if you do not calm the stomach prior to the taking of the sodium pentobarbital, there could be vomiting, and this could cause a coma but not death, or the doses which has been swallowed has not been sufficient. So therefore, this is very important that no risks will turn the bad way.

Why do you tell them to bring family?

First we tell them very early: "Speak with your relatives; speak with your family about your idea. Give them the opportunity to discuss with you, to understand why you do want to go this way, because if you would just come to Zurich and die without having told them before, they would all be shocked, and they would not be able to understand." This happens always if you have so-called normal suicides. The family has questions that nobody is able to give answers to these questions, and this is an awful situation for the family.

On the other hand, if they are discussing with the family, they will have just at first opposition, of course. But after some time the family will accept. If they can come with the member to Zurich and be present, they can say goodbye, and we know that afterwards they have no problems. Of course they will mourn -- that is quite natural when you lose a member of your family -- but you will not be depressed. You can accept this. You can accept this issue of this illness and of the situation of this person. And I always tell them, "This is a service of love," a real service of love, because with this service, you do not get something; you give something.

What if the family does not want to come?

If the family does not want to come with a member, we will have to accept that. But for us, this will not change our decision, because we are working on the basis that individuals are autonomous, and if a member has decided to end their life, then we will have to accept them. ...

We have still a member who has said to us, "Well, I will come to Zurich, and then we will proceed, and after that you will inform my wife." Then I told this 90-year-old: "But I think this is not very fair. It is not fair in view of your wife, and it is not fair in view of Dignitas, because if you would proceed this way, your wife could get very angry. This angriness would not take the direction of you because you do not exist anymore, but could take the direction of Dignitas, and therefore it is also not fair to Dignitas. So please speak to your wife." Then he did it, and one or two years later he made a visit here to us, and he brought along his daughter. Now things are in order, and we are still waiting.

From time to time he tells us that he just has something else to do, that he has to write an article but that perhaps he will come within the next three months. Then he is writing: "Well, there is something else which has happened. I have to fulfill still some other things." I am not persuaded that he will come back. But for him it is very important to know that he could if he [wanted to].

Do people change their mind here?

Yes, we have [seen that]. We had a 27-year-old Irishman. ... He had been in a wheelchair. I brought him to the apartment. The doctor came to the apartment, had the discussion with him, had written the prescription. Then I told him: "The fact that you have come to Zurich does not mean that you have said A and that you are forced now to say B. If you want to go back to Ireland, we would be happy for you to do so." Then he answered, "Oh, no, I have made up my decision now, and I will now die."

Then I told him, "Well, so I will take with me your wheelchair, but if you would decide the other way around, just a phone call, and half an hour later I will be back with your wheelchair." I went to my home, and I hadn't been here for half an hour, I had a phone call: He has decided to go back. So I went again in town, brought him his wheelchair. I laid my hand on his shoulder and said: "I congratulate you for your decision, and you will not have to look now for a hotel room until Monday, when your return flight has been booked. I will have you as a guest in my house." This was on Friday. On Saturday we had discussions here all day; on Sunday my partner was here, and then we went all three to Zurich.

There was a cemetery where James Joyce is buried. We paid a visit to his grave, and after that we went to the Zoological Garden, which is very nearby. And so we passed the whole Sunday, and on Monday I brought him to the airport, and he flew back to Ireland. ...

Later he came again and said: "Now I would have to go into a home, and [I] do not want to go into a home, and now it is time for me. In the meantime, I have found a good relationship with my mother, which has been bad before, and everything is in order, and now I can leave."

Yes, he died. The evening before we [had] been in town at a dinner together, and it was very, very peaceful.

Does it happen often?

It does not happen very often, but sometimes. ...

Does the doctor ever say no?

We have had one case, a man coming from Berlin. It was cancer, and after the discussion with the doctor, the doctor said to him, ... "You should try another pain therapy first." Then this member has been convinced of that, went back to Berlin and got morphine, and 14 days later he came again and said, "The side effects have been much more negative than the pain, so therefore I will stop now."

How long does an accompaniment take?

... Sometimes it takes three hours, sometimes more than one day. In exceptional cases -- we do not know why -- we have to wait hours after that member has fallen in coma until death has occurred. [It] may be that in those cases there is something wrong with the possibility of this organism to get pentobarbital into the blood circulation. This may cause this delay. But it is very, very rare.

It takes some time.

Yes. And we are always working open ended. We also say to our member and to the relatives, "If you need still some time to be alone, then our escorts will go away for several time and come back after that." We are never in a hurry; we are never pressing. It is always so the member [who] wants to go is the director of the time; we are the directors of the technique.

Timing of death [is] controlled by member.

Yes, it is always the member which decided at what moment he wants to drink or administer the medicine, by gastric tube or by profusion.

Do doctors resist collaborating?

We have always some difficulties to find doctors which will cooperate with us, and that is quite natural, because doctors have learned that they shouldn't do that. But since the progress of medicine has a double aspect -- sometimes it is progress, but on the other hand, it makes [it] longer and difficult to die -- we have to look for a new attitude for that. We have found doctors telling us: "I have also to take the responsibility for the dark side of medicine progress. Therefore I am willing to help those persons in speaking with them and in writing those prescriptions."

How many doctors work with Dignitas, and what kind of doctors?

We have about six doctors collaborating with us. We have some retired doctors among them; we have some doctors which still are working normally in their office, practice. ... It is much easier for the retired doctors and also for us, because they have enough time and have more capacity than doctors who are still in service.

How do you become a member?

In order to become a member of Dignitas, you fill in an application, a membership application. Then you will have to pay the membership fees, registration fees, and that's all.

How much does an assisted suicide cost?

First we thought that members would pay in addition enough fees so that they will not have to ask special payment for accompaniment. But we found out that additional paid fees [weren't] enough in order to cover the costs. Therefore we had to introduce special membership fees: 1,000 Swiss francs in order for preparing an assisted suicide; another 1,000 Swiss francs in order to make the accompaniment; and if Dignitas does have to deal afterwards with the authorities for information, for sending of the ashes in the urn, for the burial, then also another special membership fee of 1,000 Swiss francs.

So if you take the total [including] the payment for the doctor and for cremation, you will arrive at 5,000 Swiss francs, about 3,500 euro, about 4,500 American dollars.

Editor's Note: According to a February 2010 article in The Wall Street Journal, Dignitas' fee is now 10,000 Swiss francs ($10,500).

How many assisted suicides do you do in a year?

Since we have started, we have had nearly 500 accompaniments. Last year, 2005, we have had 138, 78 from Germany. The others [were] 12 from Switzerland, 12 from France, I think 14 from Great Britain, two or three from the U.S. Well, we have members in more than 50 states.

Editor's Note: According to The Wall Street Journal Dignitas helped 90 people die in 2009 -- a decrease from previous yearly averages of 135. The decrease was due in part to new restrictions requiring two doctors appointments prior to the suicide.

How many members?

Actually about 5,300. ... Every article in a newspaper, even if it is negative, brings us new members.

Editor's Note: According to a March 2010 article in The Atlantic, Dignitas now has 6,000 dues-paying members.

[Do you get a lot of] negative press?

Oh, yes, we get a lot of negative articles in the newspapers, especially in Switzerland. But this is an old story. The prophet is of no worth in his own country.

How do you feel when you meet a member coming to die?

I do not feel very happy that this member has had to make this trip, sometimes very long trip if you think that we also have members coming from Tasmania, from Australia, from America and Canada. But the fact that this member will die within several hours doesn't affect me, because in a cosmological scale, this person is just going in front of me with a distance of some milliseconds. I also will die. I know that exactly. As long as I can help people I will help them, and after that I will die. Therefore, this will not affect me. ...

[How do you think about] your own death?

If I think about my own death, I would prefer to die like my grandmother, mother of my father, has died: She [had] been in her garden, and she had a sudden stroke, and she fell among her flowers, and she was dead. But this sort of death today is very rare. It is a consequence of the progress of medicine, that a growing part of the dying people have to die with pain, with suffering over a long time, and this is a change which would be considered when we discuss assisted suicide and freedom of decision. ...

[Some have called what you do "death tourism."]

... [Zurich prosecutor Andreas Brunner has] expressed that perhaps Switzerland or Zurich could be seen as the capital of death tourism in the world and this would give a bad image to Switzerland or to Zurich. But our experience is the opposite. If we speak with people in other countries, they tell us: "What a marvelous country you are. You have this freedom, and I am very happy that I will be able to come to Switzerland if the case is so that I do need that."

[You think this is a] positive thing for Switzerland?

Like everything, also assisted suicide by Dignitas in Switzerland has two sides, a sunny side and a shadow side. We have to accept that. ...

We have always critics, and [it must have] the result that we pay attention to the quality of our service. ... Only critics which say something which is true and which would be negative for us could hurt us. ... If something is printed or said on television which is not true, it doesn't matter for us. ...

You are critical of the suicide problem in other countries, like Canada.

... I think that we should see that problem as a human rights problem. Human rights are rights which do interest always just a tiny minority. The mainstream has never trouble with the state, with police; they will never touch the borders and never have to ask for [respect of] human rights because they never are in a danger. But tiny minorities need human rights, and I think that the faculty to have an assisted suicide, when I need it, belongs to the human rights, to the respect of personal life and personal decisions. ...

Now, there are a lot of opponents which are telling us, "We cannot agree because this would have the consequence that we come to a slippery slope." Well, it's very interesting that this dangerous slippery slope is not really existent. For instance, the city council of the city of Zurich in the year 2001 has decided that people which are residents in home for old people in the city of Zurich may have assisted suicide in the homes. Formerly it was forbidden.

I have phoned two weeks ago to the chief of the health service of the city of Zurich, city physician Dr. Wegstein, and I've asked him, "How many assisted suicides do you have every year in the Zurich homes of old people?" And he told me, "We have more than 3,000 people in these institutions, and we have every year none to three assisted suicides." This number has not increased since the year 2001. ...

[What does the public not understand about the issue?]

The whole issue is not in the public field. It is covered by a taboo, and we should speak about it. We should not speak about a single suicide which has happened, but we should speak about the situation, and we should speak about how could we establish a system of prevention which would have a much better effect than the actual system. ...

Whenever we see the statistics of suicides, we see that there are horrific numbers of suicides. For instance, in Germany, every 45 minutes a person is killing themselves. Every 59 seconds there is probably suicide attempt which fails.

The consequences are not only heavy for the person, which sometimes will lose a lot of health -- for instance, kidney, liver and so on -- but we have also huge financial consequences in our health systems, and nobody cares about [that]. The darker basis on this issue is ghastly. We should know much more about. We should see that it is very important to deal with this issue and to think over our attitude to this situation. But it is still the taboo which reigns. ...

Have you had couples as members before, like [Betty and George] Coumbias?

Yes, we have had one or two. It is very, very rare of course, but it has been possible before.

With one is good health?

Yes, we had this situation. That partner has been healthy, and we have found a doctor willing to write a prescription.

Why should she be allowed to die?

If somebody has been married for 50 years, they are in old age, and they are going to be lonely after that, when the husband has died, and if this person thinks it would be better that we could die together, why should we say no? With what reason should we say no? We should allow this freedom of decision. I see no ground to say no.

She is healthy.

Even if the person is healthy and may live 20 or 30 years more, because this should always be the decision of the individual when the decision has been reflected, and I have the impression in this case that the decision has been very well reflected. ...

Should there be restrictions on this right to die?

I do not think there should be any restrictions to take one's own life, because restrictions always have as consequence that you have lonely suicides with heavy consequences to the suicidal person, to the relatives, to the health system. Freedom cannot be restricted, as long as you do no harm to other[s], a long as you do not endanger freedom of others. The borders of freedom are always the freedom of the others. ...

posted march 2, 2010

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